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Miscellaneous - 509 FOSTER STREET 4/30/2018 (2)
509 FOSTER STREET 210/104_B-0176r0000.O APPLICANT: Milltown U _1 COMMONWEALTH OF MASSACHUSETTS Z EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENT-AL-P-ROT.ECT ON_— . TOWN OF NORTH ANDOV_ri/ BOARD OF HEALTH JAN 3 1 W TITLE 5 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_509 Foster Street _North Andover_ Owner's Name:_David Cohen_ Owner's Address:_509 Foster Street- -North treet_North Andover,Ma. 01845_ Date of Inspection:_1/21/2002_ TOWN OF Nnp'` .� -3/ BOAR^ ;1 Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc._ y i Mailing Address:_111 Argilla Road_ FER — I Andover,Ma.01810 Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT w 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 fimction 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 Furdus Evaluation by the Local Approving Authority Fails C Inspector's Signature: , ate: _1/21/2002_ The system inspector shall submit a Ynpy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_509 Foster Street_ _North Andover— Owner: Cohen Date of Inspection:_1/21/2002 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: _X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_509 Foster Street _North Andover_ Owner: Cohen Date of Inspection:_1/21/2002_ 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 i of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:_509 Foster Street_ _North Andover— Owner: Cohen Date of Inspection:_U2112002_ D. System Failure Criteria applicable to all systems: You must indicate"yes"or`no"to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _No_ Liquid depth in cesspool is less than 6"below invert or available volume is less than'h 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 H 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:_509 Foster Street_ _North Andover— Owner: Cohen Date of Inspection:_l/2l/2002_ 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? NIA _ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Yes_ Was the facility or dwelling inspected for signs of sewage back up? Yes_ _ Was the site inspected for signs of break out? Yes _ Were all system components,excluding the SAS,located on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the bales or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no Yes _ Existing information.For example,a plan at the Board of Health. _No_ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_509 Foster Street_ North Andover— Owner: Cohen Date of Inspection:_1/21/2002_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design):_4� Number of bedrooms(actual):_4_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 Number of current residents:_1 Does residence have a garbage grinder(yes or no): Yes_ Is laundry on a separate sewage system(yes or no): No_ [if yes separate inspection required] Laundry system inspected(yes or no): Seasonal use:(yes or no):_No Water meter readings:_On well water_ Sump pump(yes or no); No_ Last date of occupancy:_Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information:_Pumped 98,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:_15 years old,owner_ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of I 1 OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_509 Foster Street_ _North Andover_ Owner: Cohen Date of Inspection:_121/2002_ BUILDING SEWER(locate on site plan)X Depth below grade: 18" Materials of construction:—X cast iron _X_40 PVC other(explain): Distance from private water supply well or suction line:_>100' Comments(on condition of joints,venting,evidence of leakage,etc.):_4"Cast iron thru wall.3"PVC in house. No leaks. SEPTIC TANK: X locate on site plan) Depth below grade:_6" Material of construction:—X—concrete_metal fiberglass polyethylene other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth 3" Distance from top of sludge to bottom of outlet tee or baffle: 24" Scum thickness: 3" 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:_19" How were dimensions determined: Subtract scum&sludge depth to tee length._ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): Pumped septic tank.Inlet baize ok.Inlet tee ok.Outlet tee ok.Depth of liquid at outlet invert.No evidence of leakage._ GREASE TRAP: (Ioc ate 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:_509 Foster Street_ North Andover — Owner: Cohen Date of Inspection:_1/21/2002 TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches,etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:_0_ Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of leakage into or out of box,etc.):—D-box level&distribution equal.Has flow equalizers in all pipes out of d- boz.Slight solid carryover,pumped d-box to clean.No evidence of leakage._ PUMP CHAMBER: (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of I I OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_509 Foster Street_ _Nort'h Andover_ Owner: Cohen Date of Inspection:_1/21/2002_ SOIL ABSORPTION SYSTEM(SAS):X(locate on site pian,excavation not required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: —X_leaching trenches,number,length:—4 trenches 57'long_ leaching fields,number,dimensions: overflow cesspool,number: innovative/altemative system Typetname of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation cover in snow.No evidence of ponding to surface._ CESSPOOLS: (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_509 Foster Street_ _North Andover— Owner: Cohen Date of Inspection:_1/21/2002 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. Driveway ater pipe House B ck Door A B Deck Septic Tank 2 1 D- AtoI=14' Box A to 2=14' A to D-Box=19'2" B to 1=25'8" Bto2=32'7" B to D-Box=35' 57' T Page 11 of 11 OFFICIAL INSPECTION FORM ORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_509 Foster Street_ _forth Andover — Owner: Cohen Date of Inspection:_1/21/2002_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water G feet Please indicate(check)all methods used to determine the high ground water elevation: X Obtained from system design plans on record-If checked,date of design plan reviewed:_9/5/1985_ 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: 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: 509 Foster Street, North Andover Owner: Cohen Date of Inspection: 1/21/2002 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. 4N!eiIJ. B eson Bateson Enterprises, Inc. COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617)292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B.STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Aeldrssa: ko-1 , ��. Nanta of Owner % �^^ �S!C� Address of Owner- Date of Inspection: 4 h—qql ,�\ SL(- �. Q Name of kapeetor:(Plesse Print) r" `y. I2 \ / 1 erns Dr7ged system to Seection 15.340 cif Tide S(31 O CMR 15.000) Company Name: c - { ' Mating Address: ��}DJ(� 4 �-! Of i00 Telephone Number: CERTIFICATION STATEMENT 1 certify that 1 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ asses _ Conditionally Passes _ Neols Further Evaluation By the Local Approving Authority _ ts1.� Date: Lt— —qC? Inspector's Sigttenrre The System Inspector all submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within thirty(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 Department of Environmental Protection. The original should be seat to the system owner and copies sent to the buyer,if applicable,and the approving authority. NOTES AND COMMENTS �a_3 �k_Svae_� tom_ (-7 revised 9/2/98 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON. NIA 02WS G17-'_�9,5 01- _; WILLIAM F.WELD Qc� � � TRUDY COXE Govcmo: �,. -�" - Secretary ARGEO PAUL CELLUCCI ;moi DAVID B.STRUHS Lt.Govemor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION-FORM Commissioncr PART A _ FF CERTIFICATION PropT50-9.- erty Address: _ _. N. !" ""A�dr� ner. Date of Inspection.- `(cam� �� (If different) Name of Inspector. (y 12-4 lam a DE pro ed s stem insfor ursuan to Section 15.340 of Title 5 (3 10 CMR,15.000) Company Name: Tvsc - Moiling Address: It 4Ltgnapct`{4 GIei Icv Telephone Number; — 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 inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems. The system: _ Pas onditionally Passes Needs Further Evaluation By the Local Approving Authority F Is Inspector's Signature: o' Date: �y s 17� The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. COMMENTS: B] SYSTEM CONDITIONALLY PASSES: �neorre system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon c mpletion of the replacement or re ir, as ap roved b the Board o Healt will pass. Indicate yes, no, or not determined (Y, N, or D). Describe basis of determination in all instances. If of determined", explain why not. _ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20)years prior to the date of the inspection; or the septic tank, whether or not metal, is cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspectign if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 04/25/97) Page 1 of 20 DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep ^ Primnd on Rervded Paw SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: © p3e. Owner: Date of Inspection: Bi SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed the pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with app Board of Health). Describe observations: broken pipe(s) are replaced obstruction is removed distribution box is levelled or replaced _ The system required pumping more than four 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 Cj 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 the public health, safety and the environment. �) SYSTEM WILL PASS UNLESS BOARD OF HEA LTH NOT FUNCTIONING IN A MANNER • WHICH WILL PROTECT THE PUBLIC HEALTH AND 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. ETE 2) SYSTEM WILL FAIL UNLESS THE BOARD O� HEALTH U PUBLIC HEALTH AND SAFETY ANDSUPPLIER, IF APPRPRIATE) T HERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE ENVIRONMENT: _ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. 1 well. _ The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply _ The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a or coliform bacteria and volatile organic compounds indicates that private water supply well, unless a well water analysis f the well is free from pollution from that facility and the presence of amroximat ongnot v dind d). nitrogen is equal to or less than 5 ppm. Method used to determine distance (aPP 3) OTHER n (roviil*d 04/25/97) Page 2 of 10 �r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A z n CERTIFICATION (continued) Property Address: "u — Owner; Date of Inspection: to Dy SYSTEM FAILS; You most indicate either "Yes" or"No" as to each of the following: (have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an 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 1/2 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 Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. r Any portion of a cesspool or privy is within a Zone I 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. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: You must indicate either "Yes" or"No" as to each of the following: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. n (roviaod 04/25/97) Pag* 3 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: s(pq �V. ov —A—t&Ajic Owner: � Date of Inspection: Icy--- Check if the following have been done: You must indicate either "Yes"or"No" as to each of the following: Yes Pumping information was provided by the owner, occupant, or Board of Health. Zl�_ None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. _IV/A— As built plans have been obtained and examined. Note if they are not available with N/A. L/ The facility or dwelling was inspected for signs of sewage bads--up. The system does not receive non-sanitary or industrial waste flow. The site was inspected for signs of breakout. ��- All system components, excluding the Soil Absorption System, have been located on the site. The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge,depth of scum. The size and location of the Soil Absorption System on the site has been determined based on: The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of r' / Sub-Surface Disposal System. L" Existing information. Ex. Plan at B.O.H. _�_ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) [15.302(3)(b)) n (revised 04/25/97) Page 4 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: SC)Q' ©r. S� , tjo(--V& 4j,�� Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL:,,, Design flow: d. . Number of bedrooms: Number of current residents: Garbage grinder (yes or no):-� Laundry connected to sysjem (yes or no): V06– Seasonal use (yes or no): 1v0 w�i (J1 �� Water meter readings, ifavailable (last two (2) year usage (gpd): C'� 1 Sump Pump(yes or no): Last date of occupancy: COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: gallons/day Grease trap present: lyes or no)_ Industrial Waste Holding Tank present: lyes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: �f System pumped as part of inspection: lyes or no) 2 If yes, volume pumped: t gallons Reason for pumping: TYPE O f MTEM ;/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) I/A Technology etc. Copy of up to date contracts Other APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) ND (revised 0{/25/97) page 5 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: �v Date of Inspection: BUILDING SEWER: (Locate on site plan) '� tl Depth below grade: �— �� Material of construction- t ion_�0 PVC other (explai -� �uG N k6,j�? u �— fc� Distance from private water supply well or suction line � Diameter Comrj►ents: ISO i ionc�of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) rr Depth below grade:, Material of construction: ,_ oncrete _metal _Fiberglass _,Polyethylene _other(explain) If tank is metal, list age_ Is age confirmed by Certificate of Compliance _(Yes/No) I 1 Dimensions: LD X 5, •�' �"' ��� Sludge depth: It Diseance from top of sludge to bottom of outlet tee or baffle: �� _�, Scum thickness: yytt Distance from top of scum to top of outlet tee or baffle:YIA- � Distance from bottom of scum to bottom of outlet tee or baffle: Now dimensions were determined: Comments: (recommendation for pumping, Gond off inl t and putle tees or affles, epth of Ilquid,evel in re atio to outlet in ert, s ru nal ©k�- integrity, eviclence of leakage etc.) O GREASE TRAP:V\DN%f— (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: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structure integrity, evidence of leakage, etc.) (revised 0{/25/97) Page 6 of 10 . s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 5-0q �`�= . tic cv,�– Owner: )( - Date of Inspection: TIGHT OR MOLDING TANK: (Tank must be pumped prior to, or 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 level: Alarm in working order_ Yes; _ No Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX. (locate on site plan) Depth of liquid level above outlet invert: Comments: (not if lev I and distrib ion is equal, evide ce of solids carryqq��er, e ' nce of I kage into or out of bo et 2 L t ,�. A PUMP CHAMBER: �Q (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (r*viaed 04/25/97) Page 7 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:So q � j4,p� S+: Owner: N—tj (A p� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):_ G�'' (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: Q � f leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Alternative system: Name of Technology: Comments: (no_ condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) ``3750a4i*�ZT,- C %!R ) P__ CESSPOOLS: v �Q (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: V\0V\P—. (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.) !f (saviaad 04/25/97) Pay a of 10 < SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFOR,M�A�T+IO.N (continued) ProPerty Address: Q� �'t' � Owner: V t -._ Date of Inspection; V SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) 1 t q I a I C06C,jc -,77 Wallas ec W� waw l l (revised 04/25/97) Page 9 of 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C s SYSTEM INFORMATION (continued) Property Address: 5Q ��`l� ! "..'C Owner: Fu t(�_ Date of Inspection: 11 for Depth to Groundwater 6 Feet Please indicate all the methods used to determine High Groundwater Elevation: Oab ined from Design Plans on record . Observation of Site (Abutting property, observation hole, basement sump etc.) Determine it from local conditions Check with local Board of health Check FEMA Maps s Check pumping records Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. Must be completed) (rovioed 04/25/97) Page 10 of 10 Tel: (978) 475 - 4786 Fax: (978)475 - 5451 aATFSON ENTERPRISES, INC. ExcaV�l!no 4 Wates 4 S w or Liom-Sepoc Systems&Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 5 b q � �-mac► �� ®{ Owner: Dato of Inspection: My report contained herein does not constitute a guarantee of future usaoo Clod the funptionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any fiuther operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. h Page 11 of I 1 9 y S� APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: - � 1 CURRENT INSTALLER'S LICENSE# LOCATION: S07 t6 5ler S/ , LICENSED INSTAL SIGNATURE: TELEPHONE# CHECK ONE: REPAIR: NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS-BUILT. Administrative Use Only $75.00 Fee Attached? Yes No Foundation As-Built? Yes No Floor Plans? Yes No Approval Date: Town of North Andover, Massachusetts Form No.3 NORTti BOARD OF HEALTH��^\ , 19 O 9 ... • o -Z • DISPOSAL WORKS CONSTRUCTION PERMIT Applicant AME ADDRESS TELEPHONE Site Location - —� �`1 4 A Permission is hereby granted to Construct ( ) or Repair 1�4 an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. Cr CHAIRMAN, BOARD OF HEALTH Fee D.W.C. No/ b 63 Memorandum .................................................................. To: File CC: From: Susan Ford Date: October 22, 1998 Re: proposed addition at 509 Forest Discussion with Neil Bateson,septic inspector,concerning the addition of a sun room and expansion of the kitchen. He indicated that the Title V showed a need for a new D-Box and they plan to move the tank to allow for the addition. It appears that the system was sized for 600 gpd, .... ...... ... ........ whish should be sufficient. The applicant was advised to draw up plans for the project,then apply .............. ............ ................ ............. -...... .... ................. ..... .................. ................ Building.................. .................. for.a bin. fpr � J, ng permit. In this way we could turn this hypothetical question into reality. .................. ................... ... ............. ...- ...................... .........- ......... .................... .........-..... ................... .. ..... .......... .......... ..........- ........................ ......... ...... ........................ 10ceived4tallfrom homeowner on 10/22/98. Passed on the above mentioned information. The ............... ........................ ........ ........ ............ ........................ ......................... .................... ...........-1,.............'..,....' h owumis in the process of having plans drawn and will file as recommended. Once approved ........................ ........----....... .1.......... ..... .............. .................--.... ...... ........ ........... .......... ......................... .... y, b ft. .. .......... the work on the system can wait until the time of the addition construction. .......... ..........-........- ....... ...... ... ........ ......... ............-- -1.......... ...........--- 11 .......... .............. .................. ..................... ...........- ...... ............---l'' ...........- .... .......... ............. �I...........- ... ...........-- - ...........- .................. .......- --..... ......... ............ .................. ............. .......... ............ ............... 11............ ...........---- .......... ........... .............. ................... .......... ................. 1-.......... ........... ................. ............I ............. ................. ..........- .... ............... ..........11 ............. ............... .......... ... ............. ........ ...-- ...... ........ ..... ...... ................... .......... ........... ............ ................ ......................... .............................. . ............... xxxxxx ........................ ........ . ................................. ............. ........... . ........ ........................... "X .................. ........................... .......... .............................. ........................ .. ................. ............................ ................... ..................................................................... ............. ............... ....... ............... ............. ............... ............... XXXXXXXX X: ............................. .............. Water Pumps d 'n �p- n ,� Sewage Pumps IF ELL & PUMP C®e Artesian Wells 9 RI 28 WINDHAM,N.H.03087 �V Water Softeners `011 R SE [603]898-4232 a [603]627-9533 o [617]887-5888 Water Tanks Water Testing MILLTOWN REALTY TRUST Pump Parts 95 MAIN STREET NO. ANDOVER, MASS. 01845 Motor Controls Switches OWNER'S NAME OR SAMPLE LOCATION. Guages LOT#4 FOSTER RD. NO. ANDOVER Softener Salt Resin Cleaner WATER TEST RESULTS 12/9/85 TEL NO 685---7633 � * Rust Remover HARDNESS 68.4 (0-50 REC STANDARD) Potassium Permanganate IRON 3 (0—.3 REC STANDARD) MANGANESE 0 (0—.05 REC STANDARD) Soda Ash HYDROGEN SULFIDE 0 (0—.01 REC STANDARD) Ph(ACIDITY) 7.5 (6.5-7.5 REG STANDARD) Lawn Sprinklers TURBIDITY 0 (0-20 REC STANDARD) CHLORIDES 18 (0-150 REC STANDARD) Chemical Feeders COLIFORM BACTERIA NEG (0 REQUIRED STANDARD) NITRATES 0 (0--10 REC STANDARD) Tank Alarms NITRITES 0 (0-10 REC STANDARD) SODIUM 11 (0-150 REC STANDARD) Hoist Service Portable Pump Pullers TESTED BY. Air Compressor Trencher ABOVE TESTS MEET REQUIRED STANDARDS AND BASED ON THESE, Pipe Pullers WATER IS SAFE FOR HOUSEHOLD USE AND HUMAN CONSUMPTION. THERE ARE OTHER LESS COMMON MINERALS WHICH CAN AFFECT QUALITY OF WATER. Goulds Aermotor Jacuzzi Aquatron Wel I-X-Trot Aqua-Air BOARD OF HEALTH Town of North Andover,Mass . Permit #�� �i�y� Date/xo (o APPLICATION FOR WELL & PUMP PERMIT Application is hereby made for permit to drill a well ( ) . Application is made to install (_) ap stem. Location: Address -Lot # Owner v _Address /!�/ ( U�4'�Te1 Z C Well Con ractor2 ` Address 2 Tel ZJ'Z Pump Contractor > Addres WELL CONTRACTOR (T be completed at time of pump test ) Type of Well ?2 Well used for. — 4r- Diameter Diameter of Well Size of Casing Depth of Bed Rock Depth casing into Bed Rock,__ Was Seal Tested? Yes _ No (_) Date of Testing '�/��� Depth of Well 0�� Well Ended in What Material` Depth to Water 6Z0 Delivers�_Gals .Per Min. for 4 hours i Drawdown 90 feet after pumping hours at GPM Date of Completion 1 ' .r C Signature Well Contractor PUMP INSTALLER (To bo' -filled in b ore i. stallation) Size & Name Pump dt� Pump Type Used , ✓ Water Pump Delivers _GPMSize of Tank. Pipe Material Used in Well : Cast. Iron (`) Galvanized (_) Plastic Well Pit ( ) or Pitless Adapter _ E� C� Was sleeve used to protect pipe? Yes ( ) N0 ) Type or Name Well a -. Date spskohs'r�k94s�s�sks� s� rs�srs�shs�s�rshsss��ts�s�s�s�s�slrs�s�s�s#s�ss'� ss �rs : : ^ gp` -j-jcV T , ,� ii� r�e Date Water analysis report submitted to Board of Health Date release given m owner of record & Bldg. Insp Health Inspector Health 4suBs[aRmE DISPOSAL DESIGN CHECK LIST lace IX& -IES+6'09 z'• _1C0W 5 O-K. LOT &PPROVED DATE DISAPPROM DATE Provided: Reasons: a� - TJ�v G Title V PAIL Cg Reg -2.5- The submitted plan must show. as a minim : a) the lot to be served-area,dimenaions lot V,abutters b location and log deep observation hoes-dsL+,once to ties c location and results percolation tests-distance to ties d design calculations & calculations showing required leaching area e) location and dimensions of system-including reserve area if) existing and proposed contours g) location any wet areas within 1001 of sewage disposal system or disclaimer-check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system or disclaimer (i) location any drainage easements within 1001 of sewage disposal system or disclaimer-Planning Hoard files (J) known sources of water supply within 2001 of sewage disposal o system or disclaimer (k) location of any proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 .'rom leaching facility (m) location of benchmark (n) driveways (o) garbage disposals (p) no PVC to be used in construction (q) profile of system-elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, dis ribution field piping and other elevations (r) maximam ground water elevation in arr a-wage disposal system (s) plan mast be prepared by a Professional h ,-sneer or other professional authorized by law to prepare such plans T 6 Septic Tanks (a) capacities-150% of flow, water table, tees, depth of tees., access, pumping (b) cleanout (c) 101 from cellar ,-all or inground sw4mm3.ng pool (d) 251 from sabsurface drains .2 Distribution Boxes (a) slope greater than 0.08 4 (b) soup "3L4osT� J SS 5 PVIC sy STS VES16 J �PP�{ovC-v DAr�' APR?Ou NG Aurhol?)TY 1 coi)PiTIO"5 �I,�APPRnv5D DgTE R�QSoNs D StPrc c SYSTEM l J STA U-, TIOAJ CX4V4T(oI-J )NSPt=6 i(o,v S [l 1--4'L- FMLAPPF�DVAL APPRal v)6 6 u i Hog I r/t SawteaNe ca IL-1 a�-T �►k5 (oT 3 Z-dra r&_ �pr t', S T 11OCT I-Gd vKTf men �i�; i � v�fT. �lo►� �'ro 4r -10)wces ti Imi111111111r � /11/1111 1111►31111111111� �n N111111 IIIIIIIINIIII� � ' 111 NIIIIIIII MINE IIIIIInN1E��11111111111I IIIIIIIIIIIIINIn111i11111111111 IIIIIIIIIIIIIIIIn1111111111111111 � �3, �.M 111111111111h1- � 11111111111111 i 11 111111111111111 111111` 11111111 111111111111111 IIIIIIf�i11111111.�111N11NME ; IIIIIIIIIIIIIi11N111i1111111N F INIIN111111AIIn11111111N1N 111111111l�C �Ul'i®IIIIN1111N1 1111111111lIAIInN11111111 IIIIINII�!�C�.71®NIINNIIIN ,- IIIIIIIIIIIIIIIIN IIINIIIIIIImill N1 IIINIn1i1N1 N - 111'11NIn111111 IIIININIIII INIIIINIIIIIII nIN11111111 Ii111��i111�_� IIINNIIN �IIIWN NI .` NI I r' �� 1111N11 a / f 9 Illlill1111 lt!��1111Q11111111ra111 1i111111111111i.i.�llll®1111111�111 ���� 111111111111111111111111511111t11i ���� 11111111111e111�111111111111111t11 � , - :�; 1111111111d�11'��l�1111111111111�111 � � IIIIIi1111 . 11�1�.1111111111111C111 �� � a 111111(��i11111 1111111 1111111111 � � 11111811111ONO1 IIII11 1 1 11 nl Iu11111111111111fryII I I- 111 11 11 1 IIIIn1111111111uEll 111111111111�IIII NINON I ni1n1111111111r11111111111111 In11111nn1 :�111111111111 - •> �11111111111n1�11111111111111 - n1111111111111111111111111 111111111111011rd111111111III uf 1111111111111n1®11111111111111 Mir, r 1111111u1111111111111 Inu1u1111111111111 ' a nnnlnu®®Iu1111111111111In - - - J Ell 11 n1111 1n11111111111 • n11n ,o � 1111111 111 111111 s 1®IIn1 1 ti. T 9. Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record OCT 2012 Form 4 TOWN,OFNORTH ANDOVER M s• ___.`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 hous /Rig r , Left/right side of house, Left/ Right side of building, Left/Right front of bul Ing, Left/Right rear of building, Under deck Address ock 11. - A City/Town State "\ Zip Code 2. System Owner. ��— Name Address(if different from location) City/Town State`� �^�p e Telephone Number B. Pumping Record 1. Date of Pumping 'Date 2. Quan Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes o If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: " 's) 6 e �. 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio contents were disposed: L S. Lowell Waste Water Sig Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts RECE NED City/Town of System Pumping Record OCT 2 0 Zoog Form 4 w" TOWN OF NORTH ANDOVER HEALTH DEPARTMIENT DEP has provided this form for use by local Boards of Health. tt�erforMS_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 of other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, A;jTrr_e_ar`of hous fight rear of house. Left rear of building. Right rear of building. Address City/Town State Zip Code 2. System Owner: /yv Name Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record g 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee FilterYes resent? / P ❑ tTNoIf 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: ev!�:q .D Lowell Waste Water — q r-a 9 Signature of Hauler Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANM BOARD OF HEALTH TOWN OF NORTH ANDOVER I SYSTEM PUMPING RECORD FEB - 1 2002 DATE: SYSTEM OWNER &ADDRESS SYSTEM LOCATION (example: left front of house) 11 -� DATE OF PUMPING: t f QUANTITY PUMPED k5 g;r-�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 BY- COMMENTS: COMMENTS: CONTENTS TRANSFERRED TO: Con4,, n tiv ally of Massachusetts , Massachusetts System Pumping Record System Owner System Location Date of Pumping: '— QuaWity Pumped: /�-- gallons Cesspool: No Septic Tank: No Yes System Pumped by: t5areeOa 5,rj T/mided License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: __ NORM Acao N�'�' TOw 13QARD 0�� ''� ---I l iw Gra` 1 lrt1�111Itutilr�alflt t,f Ala�kdtbutell� ' � IVlusguCllul3�tle gj"Iltltl"Utcna • •' ' , t:�lldlll�t}� ��Ulllfi�tll 1 Uete of i'utni►In� . `j /d �� ', � � � , . l.•rrr �uufl 1`11 � !' 1'r1 fiNhlld 'i'�I�l► WA rumped Licelise No S y slel 1 1 1 Cu�llenls.lrallsfeeted It'.. Uale IIIs��erlut