HomeMy WebLinkAboutMiscellaneous - 52 MARBLERIDGE ROAD 4/30/2018 (2) 52 MARBLERIDGE ROAD Dad '
210/037.A-0032-0000.0
l _ i
Commonwealth of Massachusetts
City/Town of NORTH ANDOVER, MASSACHUSETTS
System Pumping Record
Form 4
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility InformationImpor '
JUN
'J'
When filling out 1. System Location: � Iu r,, I
forms on the S2 (,/►�t AK6Qe I� TOWN of NORTH ANDOv
computer,use
only the tab key Address TMSNT _
to move your �( ) ,
cursor-do not City/Town 1v State Zip Code
use the return
key. 2. System Owner:
&, � ,
Name
few Address(if different from location)
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping "�Z' 2. Quantity Pumped: I�SUy
Date Gallons
3. Type of system: ❑ Cesspool(s) [S'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [�-40 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
%AGG S, 1,4,rC
Name Vehicle License Number
Company
7. Location where contents were disposed:
AC.
Signatu�Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
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` cfiusetts
AN[ OVER MASS'
a ,�••1��1 I � J/j•• ?r t
rr Y JUN .7 4 2007
DEP•.has provided thle form for use by local Boards of He Ith. The System PumpInj Record must
be eubmltted to the local Board of Health or other approvi g�,uthorrlt ?RTH ANDOVER
HEALTH DEPARTMENT
A: Facility Information
�-ImRortant::
�r„yvtien filum out 1 . System Location,
conputor�ns on the'; �
La.r �
only the tab key Address
61
to move your—
do
our-. , ' • Q/YI�",//1•L��.2
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r••. '^/•,.:'�tG, System
Owner', /:: •r
Name,
r• rJ'
Address(U different from location)
cllylTown State
vp e
� 9'z
' Telephone Number
Pumping Record
f is ti rlfrl �, v`, 1,
�.� ;• . Date of Pumping ' Date 2, Quant)ty Pumped; S�4
• , , Gallons
'.Type of system,-" ' ❑ Cesspools)) hep i�Tank [ITight Tank
❑'Other(describe:,
Effluent Tea Filterpresent?.❑ Yes.(moo If yes, was It cleaned? ❑ Yes— No
Co�ditlon'of*
Syst`8f rr �` F
,
.U d By
amt:;�;•;'„:;..:; '.'`�, ”, �<,:•,"' Vehicle Uoen
' .`�•'.cj;�'�.ae+•!��'`'ir.'r{`'�; i,` 1�'ri+i .'iiia"';'' �•• ee Number
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r Si�3 rtyti �+�,,�,�'� •!',;rr!,,Pt•f �' n2• it , ,•., vv�{/► / /� wl .
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+ ,J) , ,�.Kf,i�1�1�t:ttW�+.J:r}':�tt��,.�{r',"' ��{ ' Yr:. , � .r •
7 Location where,contents Were di;3posed;
:r it ,1 t_ ,• i41 ', � � �...
'• ;` k Slpnature p(Hauler,> Data
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'is .� '�,`•. .. :... .
t5forrn4.dop 08l03 System Pumping Record•Page 1 of 1
Commonwealth of Massac usetts
W city/Town of NORTH ANDOVER MASSACHUSET
System PumpingRecord
Form 4
�M
DEP has provided this form for use b I RECEI`V
y local Boards of Health. The Sysl Lm Pumping Record must
be submitted to the local Board of Health or other approving authority.
JUN - 5 2006
A. Facility Information
TOWN OF NORTH A#leis.>b'Ere
HE
Important: ALTH DEPARTMENT
When filling out 1. System Location:
forms on the _
computer, use ---- G�/Lf
only the tab key Address
to move your
cursor-do not
use the return City/Town `
key. State Zip Code
2. System Owner:
�I
Name V4 a--O�
Addressif differ
( ent from location)
CitylTown
State Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping �
Date 2. Quantity Pumped:
Gallons
3. Type of system: ElCesspool(s) Septic Tank
El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? El Yes No
If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System, a
y r!
6. Syst m PumpedBy//:
� 1� V icle License Number
C)21
Company
7. Location where contents were disposed:
0�7D
2 , �-
Sigrfature of Hauler
http://www.mass.gov/dep/water/a ovals/t5forms.htm#inspect Date
t5form4
.doc•06/03
System Pumping Record•Page 1 of 1
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BoL.ec of Health
F? e--Y-Lndover,Mass
SUBSURFACE DISPOSAL DESICK CHECK LIST
LOT
APPROPED. DATE 1- I - S DISAPPROPED DATES ,
Provided: . Reasons: i
'v� ,�s
--Tiffs V FAIL OK --
Reg 2.5 The submitted plan must show as a mdnimnm:
A) the lot to be served-area,dimensions lit # abutters
'b -distance and log deep observation holes-distance to ties
c location and results percolation tests-distance to ties
d design calculations do calculations showing required leaching area
- (e) location and dimensions of system-including reserve area
f) existing and proposed contours
(g) location any wet,areas within 100' 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
systema or disclaimer-Muining Board files
(J) known sources of water supply vithin 2001 of sewage disposal o
system or disclaimer
(k) location of any proposed well to serve lot-1001 from leaching facilit;
(1) location of water lines on property-I,' from 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 be-em. ut, plumb, pipe, septic tank,
distribution box inlets and outle-' tstribution field piping and
Otter elevations
(r) maadmnm ground water elevation in area sewage disposal system
(s) plan mast be prepared by a Professiona. Engineer or'other
professional authorized by law to prepare such plans
Reg 6 Septic Tanks
(a) capacities-1507, of flow. ,water table, tees, depth of tees,
access, pumping
(b) cleanout
(c) 10 1 from cellar wall or inground swimming pool
(d) 251 from subsurface drains
Reg 10.2 Distribution Boxes
(a) slope greater than 0.08,
Reg 10.4 b) sump
j
1 .
7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
Address of property 52 Marbleridge Road, North Andover
OF NORTH ANDOVER/
Owner's name Anthony Boschetti BOARD OF HEALTH
Date of Inspection April 21, 1995
PART A MAY 10 1995
CHECKLIST
Check if the following have been done:
XP umP g in information was requested of the owner, occupant, and Board of
Health.
X 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.
X As built plans have been obtained and examined. Note if they are not
available with N/A.
X The facility or dwelling was inspected for signs of sewage back-up.
X The site was inspected for signs of breakout.
X All system components, excluding the SAS , have been located on the
site.
X 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.
X The size and location of the SAS on the site has been determined based
on existing information or approximated by non-intrusive methods.
X The facility owner (and occupants, if different from owner) were
provided with information on the proper maintenance of SSDS.
.�
�.. �.V i
i
• SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
If residential
4 number of bedrooms
-- number of current residents
N garbage grinder, yes or no
Y laundry connected to system, yes or no
N ' seasonal use, yes or no
If nonresidential, calcul ate,.d. f lcw:
Water meter readings, if available:
300 GPD Avg. (6/22/93 to 1/27/95)
Current Last date of occupancy
GENERAL INFORMATION
Pumping records and source of information:
Last pumped 11/12/92 (BOH Records)
Also pumped 9/26/90 -
Y System pumped as part of inspection, yes or no
if yes, volume pumped . 1500 Gal
Reason for pumping:
To inspect general condition of tank, tees, leakage, etc.
Type of system
X Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
N Shared system (yes or no) (if yes, attach previous inspection
records, if any)
Other (explain)
Approximate age of all components. Date installed, if known. Source of
information:
Constructed in 1987 (BOH records)
_jam Sewage odors detected when arriving at the site, yes or no
�r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK: X
(locate on site plan)
depth below grade: 811
material of construction: X concrete metal FRP other(explain)
Precast conc. inlet and outlet tees
dimensions: L = 12011+ W = 68"+ Inv. = 49"
911
sludge depth
20" distance from top of sludge to bottom of outlet tee or baffle
1" scum thickness
4" distance from top of scum to top of outlet tee or baffle
19" distance from bottom of scum to bottom of outlet tee or baffle
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles,
depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, recommendations for repairs, etc. )
Tees in good condition, no 1 akage observed, licruid level @ outlet
invert, tank in good structural condition
DISTRIBUTION BOX: X 47" below grade
(.locate on plan)
0" depth of liquid level above outlet invert
Comments:
(note if level and distribution is equal,(n � , evidence of solids carryover,
evidence of leakage into or out of box, recommendation for repairs, etc. )
Equal distribution, no solids carryover
11
7 outlet style" 14" x 36"
PUMP CHAMBER: NA
(locate on site plan)
pumps in working order, yes or no
Comments:
(note condition of pump chamber, condition of pumps and appurtenances,
recommendations for maintenance or repairs,etc. )
10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOR1X
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) : X
(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 and number
leaching chambers and number.•
leaching galleries and number
leaching trenches, number, length
leaching fields, number, dimensions 24 ' x 55 ' , 4 distribution lines
overflow cesspool, number
Comments:
(note condition of soil , signs of hydraulic failure, level of ponding,
condition of vegetation, recommendations for maintenance or repairs, etc. )
soil is an orange brown stoney sandy loam - no evidence of ponding
or hydraulic failure.
CESSPOOLS (locate on site plan) :
number and configuration NA
. .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, recommendations for maintenance or repairs, 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, recommendations for maintenance or repairs, etc. )
0
11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100 '
See as-built plan by Joseph Barbagallo on file with the North
Andover Board of Health.
Ta t lA 17&r_fZ1 AGE P-D.
❑ � I S'od GAL.
Q-Bo
X
S,T
D-sox 43 g, . 73.7
N
DEPTH TO GROUNDWATER
84 + depth to groundwater
method of determination or approximation:
-from sniltesting conducted 4/17/84
-see plan of subsurface disposal system for this site by Christiansen
Engineering dated December, 1984 on file with the North Andover Board
of Health
-dry basement to 80" below grade - no history of wet basement as per
owner
• 12
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORS
PART C
FAILURE CRITERIA
Indicate yes, no, or not determined (Y, N, or ND) . Describe basis of
determination in all instances. If "not determined" , explain why not)
N Backup of sewage into facility?
N Discharge or ponding of effluent to the surface of the
q p g ground or
surface waters?
N Static liquid level in the distribution box above outlet invert?
NA Liquid depth in cesspool <6" below invert or available volume< 1/2 day
flow?
N Required pumping 4 times of more in the last year?
number of times pumped .
N Septic tank is metal? cracked? structurally unsound? substantial
infiltration? substantial exfiltration? tank failure imminent?
Is any portion of the SAS, cesspool or privy:
N below the high groundwater elevation?
N within 50 feet of a surface water?
N within 100 feet of a surface water supply or tributary to a surface
water supply?
N within a Zone I of a public well?
N within 50 feet of a bordering vegetated wetland or salt marsh
(cesspools and privies only, not the SAS) ?
N within 50 feet of a private water supply well?
N 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 analy:
for coliform bacteria, volatile organic compounds, ammonia nitrogen
and nitrate nitrogen.
a
13
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector Leslie P. Godin
Company Name Merrimack Engineering Services, Inc.
Company Address 66 Park Street, Andover, MA 01810
Certification Statement
I certify that I have personally inspected the sewage disposal system at
this address and that the information reported is true, accurate and ,
complete as of the time of inspection. The inspection was performed and
any recommendations regarding upgrade, maintenance and repair are
consistent with my training and experience in the proper function and
manitenance of on-site sewage disposal systems.
Check one:
X I have not found any information which indicates that the system fails
to adequately protect public health or the environment as defined in
310 CMR 15. 303 . Any failure criteria not evaluated are as stated in
the FAILURE CRITERIA section of this form.
I have determined that the system fails to protect public health and
the environment as defined in 310 CMR 15. 303 . The basis for this
determination is provided in the FAILURE CRITERIA section of this
form. Q
Inspector' s Signature 'ew "� at,�[
Date May 1, 1995
Original to system owner
Copies to: North Andover Board of Health
Buyer (if applicable)
Approving authority
ArJ
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SYSTEM OWNER&'ADDRESS !
SYSTEM L-Q ATION
lit of boun)
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r�ty � F,' i �/,�, fj � J. ..
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IF r. . ,• :'. RUQ PUMPED
GALLONS
a �! ���f�kr heft 'iM`"'f it•i a �! Y r �' d
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SEPTIC TANK:NO YES
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71
EMERGENCY
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GQOD CONDITION
C A
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B �s
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LEACHFIELD
,EXCESS R CK
IVE SOLIDS FLOODED UNBA
SOLIDS CARRYOVER OT
w HER(EXPLAIN)
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
7 -
Sl S"1'ENI
OWNER & ADDRESS -- SYSTEM LOCATION
(example: left front of house)
x- LT
A/40
D.-%'11' OF PUMPING: 016(L- QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO Y E S
.NATURE OF SERVICE: ROUTINE ✓ EMERGENCY
13.S FlZ0 N S:
GOOD CONDITION FULL TO COVER
1-1 EA V Y GREASE; BAFFLES IN PLACE'
ROOTS LEACI-IFIELD RUNBACK
F,-'XCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER 01-HER (EXPLAIN)
PUMPED BY:
I.-Nil 1,-'N'I'S:
TRANSFERRED T0:
TOWN OF NORTH ANDOV
zSYSTEM PUMPING RECO
DATE: 1 /;1,/7//0-51, JAN "M5TOWN .)VER
HEAL-i r -AT
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
THEBERGE
52 MARBLERIDGE ROAD BACK OF HOUSE
DATE OF PUMPING: 12/10/04 QUANTITY PUMPED 1500 GALLONS
CESSPOOL: NO x YES SEPTIC TANK: NO YES x
NATURE OF SERVICE: ROUTINE x EMERGENCY
OBSERVATIONS:
GOOD CONDITION X FULL TO COVER.
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: RAGGS SEPTIC SERVICE INC.
COMMENTS:
CONTENTS TRANSFERRED TO: WAYLAND-SUDBURY
lG
s� Commonwealth of Massachusetts
City/Town of NORTH ANDOVER MASSACH
System Pumping Record
Form 4 JAN 0 6 2010
DEP has provided this form for use by local Boards of Health. The SyR80st
be submitted to the local Board of Health or other approving authority HEALTH DEPARTMENT
A. Facility Information
Important:
When filling out 1. System Location:
forms on the
computer,use 5 Z m A r b t-k P-
only the tab key Address
to move your N rj y+v-t. V'—d—c�v-e-v, iM o--
cursor-do not
use the return City/Town State Zip Code
key. 2. System Owner:
bar b a v-G-t `7'i--t_ Z0 2 v-
Name
Address if different from location
City/Town State Zip Code
Telephone Number
B. Pumping Record
1. Date of PumpingDatel IS , � 2. Quantity Pumped: Gallons a0
3. Type of system: ❑ Cesspool(s) Ly'Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes M/14-0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
TOM LiviraIvt 9L35
Name Vehicle License Number
Comp
7. Location where contents were disposed:
_ Wtk4- y 501V4-('00S Gu'ou p , I a m-I-o t'1
Signature of Hauler Date
http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect
t5form4.doc•06/03 System Pumping Record•Page 1 of
RECEIVE'
� �v "j ^ 2010
Commonwealth of Massachusetts
Al. Massachusetts
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
System Pum nine Record
System Uumer bystem Location
jLI
Date of Pumping: (DZS" /o Quantity Pumped: 150 gallons
Cesspool: No U Yes . ❑ Septic Tank:: No ❑ Yes Q�
RAGGS SEPTIC SERVICE, INC.
System Pumped by: d.b.a. E_. A. COMEAU SEPTIC License r:
Contents transferred to: WATER SOLUTIONS GROUP, TAUNTON
Date 0 -,? 5- U Inspector RAGGS SEPTIC SERVICE. INC .