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Miscellaneous - 53 CEDAR LANE 4/30/2018 (2)
j 54 CEDAR LANE - - - 2101106.A-0142-0000.0 I f l 1 I i i 1 Commonwealth of Massachusetts City/Town of M :: System Pumping Record 9 2014 Form 4 TOWN OF wvrt i H ANDOVER ura� fH nFPAR. hMF DEP has provided this form ma7 N7 for use,by local Boards of Health. Other forms� a 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 Rig rear of hous. Left/right side of house, Left/ Right side of building, Left/Right front of buil Ing, Left uildin9, Under deck Add resi�9 . Ced4r L le NA At,kt( City/Town State Trp Code 2. System Owner. +o an S Name Address(if different from location) Cityrrown State Trp Code D331 Telephone Number B. Pumping Record I. 1. Date of Pumpinggate 2. Quantity Pumped: Gall[Odd 3. Type of system: ❑ Cesspool(s) ID Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yeas [a/No If,yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: II 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Location where contents were disposed: Ca!. Lowell Waste Water p -iiignAwfe 4Haule Date t5fom-A.docr 06/03 System Pumping Record•Page 1 of 1 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, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address Cityrrown State Zip Code 2. System Owner. �to Name Address(if different from location) City/rown State Zip de ; Telephone Number B. Pumping Record r J 1 C 1. Date of Pumping Date ;�epfic Quanti , Pumped: Gallons —T 3. Type of system: ❑ Cesspool(s) Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No if yes, was it cleaned? ❑ Yes ❑ No: S. Condition of stems ` Id\ 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc' Company 7. Location ere contents were disposed: a(_S'. Lowell Waste Water � t7 `' ( �` Sig a qt HaulwU Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts W City/Town of North Andover I ' System Pumping Record Form 4 G"1M 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: on the computer, I r �0_ np_ use only the tab I key to move your Address cursor-do not North Andover Ma 01845 use the return City/Town State Zip Code key. 2. System Owner: Name mnen Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: O Date Gallons 3. Type of system: ❑ Cesspool(s) El"Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes;!rNo If yes, was it cleaned? ❑ Yes No 5. Condition of System: ; U„` ol� 6. S y,,Oem Pum d By, 1' n .elVV^y, tC-U a( e Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 f_ Lo 1�IIP_ Sign ture of Ha Date / n ur of Receiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts LVVF City/Town of I 5 2007S stem Pum in RecordY p J h rH ANI�ovEr�Form 4 PARTMENT DEP has provided this form for use by local Boards of Health. The System Pumping Record must ' be submitted to the local Board of Health or other approving authority. - . A. Facility Information Important: When filling out 1. Systelin Location. comps the ` �-�_ �`"�_ C✓ C��I computer,use only the tab key Address to move your cursor-do not use the return City/Town State Zip Code key. 2 System Owner: Name Address(if different from location) City/Town State Zip Code' Telephone Number B. Pumping Record 1: Date of Bumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 9-90 If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi n of System:. 6. Syste ; P ed By Name Vehicle License Number Company .7. location whe on pts dised: Sign ' r aule D �l ate http://www.mass.ggv/dep/wate approvals/t5forms.htm#inspect t5form4.doc•06/03 System Pumping Record•Page 1 of 1 0 0 COMMONWEALTH OF MASSACHUSETTS 4 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Z d DEPARTMENT OF ENVIRONMENTAL PROTEE*ALTH a F ��M SVev`da UG 2 0 2004 OF NORTH ANDOVER DEPARTMENT TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address:_54 Cedar Lane —North Andover_ Owner's Name:John McElroy_ Owner's Address: 54 Cedar Lane_ _North Andover,Ma 01845_ Date of Inspection:8/06/2004_ Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc._ Mailing Address:_111 Argilla Road_ _Andover,Ma.01810 Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper 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 Further Evaluation by the Local Approving Authority F ' s Inspector's Signature: - Date: _8/06/2004_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments:After well water was tested&inspected by B.O.H.septic system now passes Title 5 Inspection. ****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. 08/09/04 MON 07:36 FAX 617 258 2942 DRAPER LAB Q001 RECEIVED 0 11p, AUG 0 9 2004 RAPER LABQAATOiiY ry TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 555 Technology Square, MS 55, Cambridge, MA 02139-3563 Tactical Systems Directorate ■ w ■ ■ ■ ■ ■ ■ ■ � � � � ww • ww ■ w ■ ■ ■ ■ www ■ ■ ww � ■ w ■ w ■ FACSIMILE TRANSMISSION TO: S05 aV'\ saw e,r OATEN: � /��O y y COMPANY:Nj. /4A<(11 dltle( It AW11 FAXNO: 978- 699- 9g-Y? PRONE NO: Total number of pages being transmitted,including this cover letter is `{ In the event you do no[ receive the total, number of pages indicated, please do not hesitate to call. 97g- 9 7�(-4t 7 Our PHONE number is 7 Our FA.X number is 617/258.2942 .! FROM: v (1'e- eA C-F(ro y NOTES: S y C e l k"— L.e-s 0410. /4Ar[o J2�� M 4 D g v- 08/09/04 MON 07:37 FAX 617 258 2942 DRAPER LAB 10003 Page 2 of 3 encrobac Laboratories, Inc. MASSACHUSETTS DIVISION STATE CERT ID. 148 Bartlett StreetSTATE Mar%omgh,MA 01752 Microbac (508)460-7600 Fax (508)460-7777 Daniel 1.Stemarie,Lab Director wwwmicrobac.com E Mad;massachusetl8 micr0bac-com CHENUSTRY- MTCROBIOLOGY FOOD SAFETY CONSUMER PRODUCTS WATT3`R• AIR• WASTES- FOOD` PHARMACELITICALS- NUTRACE[J I7CALS CERTIFICATE OF ANALYSIS JULIE MCELROY Date Reported 8/512004 Date Received 7129/2004 54 CEDAR LANE Sample ID 0407-01412 NOKTH ANDOVER,MA 01845 Invoice No. 82316 Cust 8 M006 Cust P.O.0 Sampled By:CLIENT-• Date 7/29!2004 Time Test Result Reg.Limit Date Time Tech Comment Viva .. I. .. �i . .. ... I le...... ..rj ,I.... .n, :}. ...•.. .,1..1.1......,»....:. ..._... .. 1, r .1.' " 2,2-Dichloroproparle <0.5 ug/L 8/2/2004 NCL 1,14chloropropene 0.5 ug/L 8/2/2004 HCL Cis-1,3-Dichloropropene <0.5 ug/L 8/2/2004 HCL trans-1,30chloropropene <0.5 ug/L 8/2/2004 HCL Ethylbenzene <0.5 ug/L 700 8/2/2004 HCL Satisfactory Hezeehiorobutadiene <0.5 ug/L 8/2/2004 HCL Isopropylbenzene <0.5 ug/L .8/2/200-4 HCL p-Isopropyltoluene <0.5 ug/L 8/2/2004 HCL Monochlorobenzene 4.5 ug/L 1D0 8/2/2004 HCL Satisfactory Naphthalene <0.5 ug/L 8/2/20(14 HCL n-Propylbenzene <0.5 ug/L 8/2/2004 HCL Styrene <0.5 ug/L 100 8/2/2004 HCL Satisfactory i,1,1,2-Tetrachloroethane <0.5 ug/L 8/2/2004 HCL 1,1,2,2-TetraCNoroethane <0.5 ug/L 8/2/2004 HCL Tetrachloroethane <0.5 ug/L S.0 8/2/2004 HCL. Satisfactory Toluene <0.5 ug/L 1000 8/2/2004 HCL Satisfactory 1,2v3-Trichlorobanzene e-0.5 ug/L 8J2/2004 HCL 1,2,4-TrithbrobenZene <0.5 ug/L 70.0 8/2/2004 HCL Satisfactory 1,1,1-Trichloroethane <0.5 ug/L 200 8/2/2004 HCL Satisfact0ty 1,1,2-Trichloroethane <0.5 ug/L 5.0 8/2/2004 HCL Satisfactory Trichloroethene 40.5 ug/L 5,0 8/2/2004 HCL Satisfactory Trichlorofluoromethane <0.5 ug/L 8/2/2004 HCL 1,2,3-Trichloropmpane <0.5 ug/L 8/2/2004 HCL 1,2,4-Trimethylbenzene <0.5 ug/L 8/2/2004 HCL 1,35-Trimethylbenzene <O.S Ug/L 8/2/2004 HCL Vily Chloride <0.5 ug/L Z.0 8/21ZD04 HCL Satisfactory Total Xylenes <0.5 ug/L 10000 8/2/2004 HCL Satisfactory Methyl t-Butyl ether <0.5 ug/L 70.0 8/2/2004 HCl Satisfactory 1,2-Dichlorobernene-d4 97%Recovery 8/2/2004 hKL p-Bromofluorobenzene 99%Recovery 8/2/2004 HCL Temperature at Lab 7.0 Degrees C 7/29/2004 ]DF Temperature in field 15.0 Degrees C 7/29/2004 )DF The dos end Inbr11 Um on dns,and eNe,a=mpaWng don w4M,reprRWR only dx ea(ftPfdv)atlalrred and Is m% ed upon oabloon MEMBER that tt Is not W be repamumd wraW or on port for wve WOO or othn PurP-wiumK aPprvral hwn the khastory. USDA-EPAduOSH Tesing rood SanAWuu CorrsuRnp omykm and M1=bob91w1 Andrie and Research 08/09/04 MON 07:37 PAX 617 258 2942 DRAPER LAB 10002 ®1Vlicrobae Laboratories, Inc. Page 1 of 3 MASSACHUSl"TTS DIVISION 148 Bartlett Street STATE CERT ID. Marlborough.MA 01752 M-MA003 Microbac 'i (508)460-7600 Fax (548)460-7777 Daniel J.Ste.Marie,Lab Director www.microbac.com E-Mail:massachusetta microbac.com CHEMISTRY- MICROBIOLOGY- FOOD SAFETY CONSUMER PRODUCTS WATER• AM WASTES- FOOD- PHARMACEUTICAi.S- NUTRACEUTICALS CERTIFICATE OF ANALYSIS JULIE MCELROY Date Reported 8/5/2004 54 CEDAR LANE Datc Received 7/29/2004 NORTH ANDOVER,MA 01845 Sample ID 0407-01412 Invoice No. 82316 Cust# M006 Cat P.O.# Sampled By:CLIENT Date 7/29/2004 Time Teat Remit Reg.Limit Date Time Tech Comment . r:,,, :. a DOSE.•.:T 3001.,.,.,.. St�1IK.., �E4AR,I11!lE.;�YO '11. 1 R,,..... . 9. ,,.....:... :..:. Total Coliform ABSENT per 100m1 0 7/29/2004 16:20 LBC Satisfactory Nitrate Nitrogen as N 0.23 mg/L 10 7/30/2004 14:15 RLC Satisfactory Ammonia Nitrogen as N <0.5 mg/1 7/30/2004 HCl Benzene <0.5 ug/L 5.0 8/2/2004 NCL Satisfactory Bromobenzene <0.5 ug/L 8/2/2004 HCL Ommochloromethane <0.5 ug/L 8/2/2004 HCL Bromodichloromet1we <0.5 ug/L 8/2/2004 HCL Brornoform <0.5 ug/L 8/2/2004 HCL Bromomethane 40.5 u9/1. 8/2/2004 MCL n-Butylbenzene <O.S ug/L 8/2/2004 HCL sec•Butylbenzene <0.5 ug/L 8/2/2004 hCL tent-Butylbenzene <0.5 ug/L 8/2/2004 HCL Carbon Tetrachloride <0.5 ug/L 5.0 8/2/2004 HCL Satisfactory ChWoethane <0.5 ug/L 8/2/2004 HCL Chloroform <0.5 ug/L 8/2/2004 HCL Chlorpmethene <0.5 ug/L 8/2/2004 HCL o-Chlorntoluene <0.5 ug/L 8/2/2004 HCL p-Chlorotoluene <0.S ug/L $12/2004 HCL Chlorodibromomethane <0.5 ug/L BMZ004 HCL Dibromorriethane <0.5 ug/L 8/2/2004 HCL o-Dichlorobenzene <0.5 ug/L 600 8/2/2004 HCL Satisfactory m-Dichlorobenzene <0.5 ug/L 8/2/2004 MCL p-Dichlorobenzene <0.5 ug/L 5.0 8/2/2004 HCL Satisfactory Dichlorodifluuiomethane <0.5 ug/L 8/2/2004 HCL i,l-Dichloroethane <0.5 ug/L 8/2/2004 HCL 1,2.Dichloroethane <0.5 ug/L 5.0 8/2/2004 HCL Satisfactory 1,1-DKhloroethene <05 ug/L 7.0 8/2/2004 HCL Satisfactory cis-1,2-Dichloroethene <0.5 ug/L 70.0 8/212004 HCl Satisfactory trans-1,2-DlchlorWhene <0.5 ug/L 100 8/2/2004 HCL Satisfactory Dichloromethane <0.5 ug/L 5.0 8/2/2004 HCL Satisfactory 1,2-Dichloropropane <0.5 ug/L 5.0 8/2/2004 HCL Satisfactory 0-Dichloropropane <0.5 ug/L 8/2/2004 HCL The data and Infannation on this,and other accompanying afm-ts,raww-t only the sarnple(s)analyzed and Is mrwared upon condition MEMBER that it Is not to Oc neporduo w wholly or in part for advartaing w outer purposes wtdholR approval from rhe laboratory. USDA-EPA-NIOSH Testing Fwd Snnkatlon fanwiMp Chemical and Miopbip iCal MaWSes and Resti aiO 08/09/04 MON 07:97 FAX 6.17 258 2942 DRAPER LAB 10004 Page 3 of 3 Microbac Laboratories? Inc. MASSACHUSETTS DIVISION STATE CERT ID. 148 Bartlett Street TfiA003 Marlborough,MA 01752 (508)460-7600 Fax (508)460-7777 Daniel J.SteMarie.Lab Dircetor crobac.com wwwmki,obac..com E-Mail:massachuaetts@mi ER 111-11,1_1 WAu7ERS AIR ASTESI FOOD- rOPHAR IACEUI7CALS STIl1TRACEUTICTALS CERTIFICATE OF ANALYSIS Date Reported 9I5l2004 JULIE MCELROY Date Received 7129/2004 54 CEDAR LANE Sample ID 0407-01412 NORTH ANDOVERMMA 01945 Invoice No. 82316 Cust# M006 Cast P.O.# Sampled By:CLIENT , - Date 7/29/2004 Time Test Result Reg.Limit Dau Time Tech Com e°• .r..;....... .•..I.•........:..3-::":....•.y:.:...�"r�:y•\.;::•...-.i.11.. I. i:',•••'..y.i f'-'i l •••/.I r ':'1•'1'':• ,•,I,r F. : ... '�'�•�• - _ S'r'i w:;••. -sl .,:.: - ,1,. -r.. :.r~..i_�C 'L:::::'`- - s..i r :•N- r- -"i7`T!�• .` :i=` ..,� -n':Rh:. .<... ':_- ."h:• {`_'^ ;F�,;r',,// h�: r'f" •"•1.:, %•fr,'• ..:pC.J^ :'iiJ,:.`;li'.: :,a?i"".'LG.a;:! „r..^.m{ii.:_'�.-. �:.r.�' ?111....:: ::^w....a,;, , . ".'.;'•Y,'. 'Ibis report has been ruviewcd and is electronically siPed bY: Daniel J.Ste.Marie LabontiaryDfimtor Rcgulstory Limits are from Feddril and State Gmdaoee docuntcuts Texts without a anted limit weused for debaouaoing aeatbctic 9ua1aY atilt'and are not indicators or known sou cce of beth effects. Comments a9 w wbethar or not any particular sample is satisfactory Is based solely upon rcgtllatta'y limits and guider+nes. All samples are listed according to doatmented and epprovad EPA methods of analysis for drinking and wastawatm. rhe dna nue.nutwn m duh„an0 etnx aatvmta»rrw • MEMBER cp-Madtheampes)K*1yndnn lost att not m be whop or In Dart to ragrq eaveor.a lulu Purposes WOW SPPMW from t!e lehoratorrl USDA#PA-t1IOSH TrIt" Food Sad .Mn Comub" Chem"and M00010G1fil Rrts�&W RaWd% �� n COMMONWEALTH OF MASSA USETT'S EXECUTIVE OFFICE OF E ONMENTAL AFFAIRS p d DEPARTMENT OF ENVIR MENTAL PROTECTION 4 H M< r. V� Sv TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 54 Cedar Lane —North Andover Owner's Name:John McElroy_ Owner's Address:_54 Cedar Lane_ _North Andover,Ma 01845_ Date of Inspection:7/20/2004 Name of Inspector: Neil J.Bateson Company Name: Bateson Enterprises Inc Mailing Address:_111 Argilla Road_ _Andover,Ma.01810_ Telephone Number:_(978)475-4786_ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection.The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to Section 15340 of Title 5(310 CMR 15.000). The system: Passes Conditionally Passes X Needs Further Evaluation by the Local Approving Authority ail 0— Inspector's Signature: Date: 7/20/2004_ The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments: ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:_54 Cedar Lane_ _North Andover— Owner:—McElroy— Date cElroy_Date of Inspection: 7/202004 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.. 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:_54 Cedar Lane_ _North Andover — Owner: McElroy_ Date of Inspection: 7/20/2004_ C. Further Evaluation is Required by the Board of Health: X_ Conditions exist which require fiuther evaluation by the Board of Health in order to determine if the system _is failing to protect public health,safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: _ Cesspool or privy is within 50 feet of a surface water _ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _X 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 Jape measure,75'to drywell_ "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:_54 Cedar Lane_ —North Andover_ Owner• McElroy_ Date of Inspection: 7/20/2004 D. System Failure Criteria applicable to all systems: " You must indicate es or fro to each of the following for all inspections: "y g _ 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 1/2 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 mast be attached to this form.] lY 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 Sow of 10,000 gpd to 15,000 gpd• You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 54 Cedar Lane_ _North Andover– Owner: McElroy_ Date of Inspection: 7/20/2004 Check if the following have been done.You most indicate"yes"or`no"as to each of the following: Yes No Yes_ _ Pumping information was provided by the owner,occupant,or Board of Health No Were any of the system components pumped out in the previous two weeks-? Yes_ — Has the system received normal flows in the previous two week period? No Have large volumes of water been introduced to the system recently or as part of this inspection? Yes _ Were as built plans of the system obtained and examined?(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,luted on site? _Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? _Yes_ _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems'? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no _Yes_ _ Existing information. _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: 54 Cedar Lane_ ' _North Andover– Owner: McElroy_ Date of Inspection: 7/20/2004_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 3_ Number of bedrooms(actual): 4_ DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): N/A_ Number of current residents:_5 Does residence have a garbage grinder(yes or no): No Is laundry on a separate sewage system(yes or no):_No Laundry system inspected(yes or no):— Seasonal use:(yes or no): No Water meter 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/sqft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no):_ Water meter readings,if available: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Pumped three years ago,owner_ Was system pumped as part of the inspection(yes or no): Yes_ If yes,volume pumped:_1000_fflllons--How was quantity pumped determined?_Measured tank Reason for pumping: Inspect tank&baffles_ 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) _InnovativetAltemative 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:_30 years old.April 1974, As built plan._ Were sewage odors detected when arriving at the site(yes or no): No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_54 Cedar Lane_ _North Andover— Owner: McElroy_ Date of Inspection: 7/20/2004_ BUILDING SEWER_X_ (locate on site plan) Depth below grade:_22"_ Materials of construction: _cast iron _X_44 PVC other Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.):_4"PVC thra wall, 3"PVC in house,no leaks SEPTIC TANK: X Depth below grade:_10" Material of construction: X concrete—metal_fiberglass_polyethykene —other(explain) If tank is metal list age:— Is age confirmed by a Certificate of Compliance(yes or no):_(attach a copy of certificate) Dimensions: 7'x 5'a 4' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 26" Scum thickness:_8"_ Distance from top of scum to top of outlet tee or baffle:_6"_ Distance from bottom of scum to bottom of outlet tee or baffle:_8" How were dimensions determined:_Difference between baffle length&scum&sludge depths_ Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.)_Pumped septic tank.Inlet baffle ok.Outlet ba1Be corroded on top.Depth of liquid at outlet invert•.No evidence of leakage._ E TRAP: ovate on site plan) GREASE _(1 p ) 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 battle: 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.): i Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 54 Cedar Lane_ _North Andover Owner: McElroy_ Date of Inspection: W20/2004_ 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 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.)_WBox level&distribution not equal.More flow to Pit#2.Installed sow leveler.Now flow is equal.Evidence of carryover,pumped d-box to clean.No evidence of leakage._ PUMP CHAMBER_(locate on site plan) Pump in working order(yes or no):— Alarm in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_54 Cedar Lane Owner: McEhoy_ Date of Inspection:_720/2004 SOIL ABSORPTION SYSTEM(SAS): X (locate on site plan,excavation not required) If SAS not located explain why: TX a leaching pits,number: 2_ leaching chambers,number: leaching galleries,number: _ leaching trenches,number,length: leaching fields,number,dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil,signs of hydraulic failure,level of ponding,damp soil,condition of vegetation, etc.):_Soil ok.Vegetation ok.No sign of ponding to surface.Pit#1 empty.Pit#2 holding 10"of liquid._ CESSPOOLS: (cesspool must be pumped as part of inspectionxlocate 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 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_54 Cedar Lane_ _North Andover— Owner:—McElroy— Date cElroy_Date of Inspection: 7/20/2004 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. A to 1=15'3" Pit# Pit# Ato2=16' 2 1 Ato3=17'5" A to D-Boz=25'2" D- B to 1=15' Boz Bto2=16' B to 3=1712" B to D-Boz=2514" 3 Deck 2 1 A Driveway House Well head 75'to Pit #2 Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:_54 Cedar Lane_ _North Andover — Owner: McElroy_ Date of inspection:_7/20/2004 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water _91 _ 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:_April 1974_ 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:_Test pit data on design plan shows 9'no water 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 t p p Property Address: 54 Cedar Lane, North Andover Owner: McElroy Date of Inspection: 7/20/2004 MY report rt 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. Neil J. B eson Bateson Enterprises,Inc. TO: NORTH ANDOVER, MASS 'S 19 -70 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at r� North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated -7 19 ' —T CC /R—eg.Irof./Yngineer/ReeSanitarian J� FORM 4•= PL:1iP�G RECORD !V'Forest St. /Mrddleton,MA 0194 (508) 774-27729 .��G v CE`N rOwN OF 5E4 5ER BOA 0 FH TMVER/ COMMOnN ealth of ASassachus tts JUN — 8 199 e 5 ,.Massachuset s : "T nlem Myin Record veep tem wn r •, ���� Ystem cation C4 7"' g � e a- �-��f-Se Date of pumpin : 7 N f� C� Quantity Pumped ]ons Cesspool: o ❑ o�t' ` es eptic Tan}:: 1\'0 ❑ Yes �! System Pumped ba: -7'�r4 / ,Contents.transferred to: License #{: L Date zt Mr Inspector Town of North Andover, MA 'wN AN watershed Septic System �kEAti�t1 Servicing Report - 8 Date: c Homeowner: Pumper 174, Street J4 4 — dress: Il Phone _ Phone —►—rr Nature of Service: Routine Emergency observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Rocts . other (Explain) Description Work: Comments: '.R't<' .rr 3,1. 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M �, � y k,�<y ,t r r p�T 4'i°'r<,�P.R i •ir5r•. i £. { �. �� ���' '�, v �� ��.r -,i��;�,������� .4 y ,'A.'.*•/�plhTr ���'j:L2 .Ir��7la' °iO 7�, ,L N� '�° t K;+�- � t y,��j�'t!� � .t k .f h�t*t��gRi• �s��'ytr} ra s Rr ' .:t i 'yi a � sfi��,yy 1.5�< 1°_•i 'L•!� >R <..,,[[ kPr, � � £�.tk�•<yy�3'..q t k.F!1-'�,Sj •'9.�:.t'.a•c• '..Y.► -rr'•� �'_8 i ��� '� �•.q'_r:w#- { i.1t frr,d�� i p. t' �,>S_ "4�� h , i .. ,� x �43� , a �z�"•d +�� m r.. �i }yam _�x� l'+ - �� , ii'"``.Y ,i - � 'tCft ,a. >s 4 m T lir •P'�4}`t'f 73�i; ¢a.{S`,I,,.. t r5E' ^,.i• t f 'r�t� 4� •I.�{� �y',/ } t •s i Town of North Andover, MA ,wN Watershed Septic System ` Servicing Report Date: Homeowner: Pumper Street _ dress: Phone _ — _ Phone ���"�!✓ Nature of Service Routine Emergency observations: Good Condition Full to Cover Baffles in Place Leachfield Runback Excessive Solids Heavy Grease Roots —. other (Explain) Description Work: 60- �e---1 L Comments: October 3, 1997 Dave Ferris DEP NERO 10 Commerce Way Woburn,MA 01801 Dear Dave: I am enclosing a copy of a Title 5 inspection report that I received from the homeowner. There are some items that leave me somewhat uncomfortable, such as the fact that it is obvious to me that the inspector did not check the Board of Health files, did not determine groundwater by any method, and indicated that there was a liquid level above the D-box outlet invert of/4 but did not specify the type of measurement the"1/4"was but still passed the system. Apparently the homeowner has had the system pumped and the pumper, also a licensed inspector, indicated there is some problem. 1.Please feel free to give me a call if you have any questions. Also,the new owner's name is John McElroy and his telephone number is 978-470-0179. Sinceyely, Sandy Starr,R.S. Health Agent F�OR'1i 4=^SYSMNI PL:1LE'L�G RECORD '0?Forest S i t. dMfddlelon,MA 01949 O�P�N (508) 774-2772 0��E rpw80AgdplANDpyEA/ H . FALTH ComrnonWealth of Asassachus tt JUN — 8 MS s X95 ---_. "Massachuset s Mem Pum prrt Record vel,"� . y tem wn. J stem cation AFY �- Date of Pum 7 � c ��-- Pumpin6J in Quantity Pumped; , 4�lons Cesspool: No` 1. 'es ❑ ° eptic Tan].: No ❑ Yes 11,_V.4' S.1•stem Pumped bv: /' -Contents trans License M "7 /1 LST i (erred to: 771, 7-d Date zt rl�'� :�� Inspector ���� October 3, 1997 Dave Ferris DEP NERO 10 Commerce Way Woburn,MA 01801 Dear Dave: I am enclosing a copy of a Title 5 inspection report that I received from the homeowner. There are some items that leave me somewhat uncomfortable, such as the fact that it is obvious to me that the inspector did not check the Board of Health files, did not determine groundwater by any method, and indicated that there was a liquid level above the D-box outlet invert of/4 but did not specify the type of measurement the"1/4"was but still passed the system. Apparently the homeowner has had the system pumped and the pumper, also a licensed inspector, indicated there is some problem. Please feel free to give me a call if you have any questions. Also,the new owner's name is John McElroy and his telephone number is 978-470-0179. Since ply, Sandy Starr,R.S. Health Agent - OA) `�2IVg7-e GU�LG - V07-��rO 3- D I D N67- T�/U4' -- Z 4sr- - 'DI D /V07- C N&C,< B611 r-IZZ- -A6&- 5 �C/'T/� d/= �/QU//J L�V�G ,f��OUE" dUTGCT /ilJ UG�T 5J`f3Tl�,D h I r � 00 y , ' c 3 � 1 1 7 1 , 1 ' 1� fi I�1 1 / , r- t ilk r s J • f Z 70 19 j NORTH ANDOVER, MASS TO: BOARD OF HEALTH Re: Soil Absorption Sewage FROM: DESIGN ENGINEER System Inspection This is to certify that I have inspected the construction of the said disposal system at North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 . /RIeg. r*ofngineer/R Sanitarian 76/10/1997 14:07 15084755101 PRU HOWE & DOHERTY E PAGE 02 nt r i F I R S T HOME INSPECTIONS, INC. SAFETY Make safety your FIRST choice. 200 am STREET BRtDGEwATm,MASSACRUSFM 02324 1.88$-SAFETY-4 1.888-723.3894 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address:$y � "t�AsE /Vc�`f1Mc/I?ue� ^.0V8VZi Address of Owner: Date of Inspection:3-a-97 (If different) Name of Inspector! .,A SCwez[ Company Name,Address and 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 tare, 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_ Passes Conditionally Passes Needs Further Evaluation By the local Approving Authority Fails inspector's Signature: Date: 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 0: Aj 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. B1 SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) ti�Printed on ROCKIed PMw 06/10/1997 14:07 15084755101 PRU HOWE & DOHERTY E PAGE 03 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:S'j' �il�e� _ /Z6:�j / ewg-y-s— OWnf r: raly►dA�+t'C Gie! :avt� Date of Inspection: 61 SYSTEM CONDITIONALLY PASSES(continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box, The system will pass inspection if(with approval of the Board of Health): broken pipets)are replaced obstruction is removed disiiibution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipets). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 khe public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _,_, The system has a septic tank and soil absorption system and is within 100 feet 10 a surface water supply or tributary t0 a surface water supply, The system has a septic t2nk and sci! absorption system and is within, a Zone I of a p;,blic svc;z; supply The system has a septic lank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic lank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis 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. 3) OTHER (revised 11/03/95) fib/lb/lyyf 14:bf 1t)db41551U1 hKu HUwt & UUhtKIy t PAGE 04 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:sY AtZme Owner: ;Wv frX,%vie, (1/E'�pl�� Date of Inspection: D) SYSTEM FAILS: I 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 c.urreo the failure. Backup of sewage into facility or system component due to an overloaded or clogged SA5 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. 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, El LARGE SYSTEM FAILS: 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 (hreat to public health and safety and the environment because one or more of the following conditions exist: 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 (IWFA) 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. (revised 11/03/95) 3 x6/10/1997 14:07 15084755101 PRU HOWE & DOHERTY E PAGE 05 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:59 efl�,Q,e~ "( '4' ,Q,�A Owners jo—n �.�aa•r P (a, oat H Date of Inspection: Check if the following have been done: C Pumping information was requested of the owner, occupant, and Board of Health. None of the system components have been pumped for at least two weeks and the system has been receiving normal (low rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. NAAs 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. 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 existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (reviled 11/03/95) 4 bb/1b/lyy! 14:bt InUd41nniU1 I•'KU HUWL & UUHtkIY t PAGE 06 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:-S'/d%q/w,4q,.,�,� ,(,(,j, /�/ileid u Owrtef--AZ; d- 4vii C. g y e)/84',— Date of inspection: 3" r �( RESID NTIAL: .t, FLOW CONDITIONS Design flow:/641 lions Number of bedrooms: Number of current residents: '3 Garbage grinder(yes or no): Laundry connected to system (yes or no): (/E� Seasonal use (yes or no):_&o Water meter readings, if available: Last date of occupancy: COMMERCIAUIN USTRIAI. Type of establishment: Design flow:.,...,gallons/day Grease trap present: lyes or no)` Industrial Waste Holding Tank present: (yes or no)� Non-sanitary waste discharged to the Title S 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: System pumped as part of inspection: (yes or no) If yes, volume pumped: Reason for pumping: TYPE,QF SYSTEM x Septic tank/distribution box/soil absorption system Single Cesspool z_ Overflow cesspool Privy Shared system (yes or no) (if yes,attach previous inspection records, if any) Other(explain) APPROXIMATE AGE of all components, date installed (if known)and source of information: •"�t oma+ Sewage odors detected when arriving at the site: (yes or no)AQ (rcvLsed 11/03/95) 5 06/10/1997 14:07 15084755101 PRU HOWE & DOHERTY E PAGE 07 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S"K Owne r N� _ (7R�D�' Date of Inspection: SEPTIC TANK:_ (locate on site plan) it Depth below grade: Material of construction: concrete_metal _FRP_other(explain) Dimensions:Iu Ep' cL S IJL--40 Sludge depth: j of Distance from top of sludge to bottom of outlet tee or baffle:,1,3L Scum thickness:t_ Distance from top of scum to top of outlet tee or baffle:z^ Distance from bottom of scum to bottom of outlet tee or baffle: /G Comments: (recommendation for pumping, conditio of inlet and outlet tees or baffles, depth of liquid level 'n relation to outlet invert, structural integrity, evidence of leakage, etc.) - r e. r«.0 ) ew( W N GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal _FRP_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: 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, etc.) (revised 11/03/95) 6 GD/Iri/1'J7/ 14;rJ/ 13U04to3lul h-Nu Huwt t& LumtNj Y t PAGE 08 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 4ow—, X /9 yr ^, Ownef:r�p„,r-�i�u/t Date of Inspection: - TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete metal_FRP_,.,_other(explain) Dimensions: Capacity:_..��al IonS Design flow:_gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOQ� (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and d.stribution is equal,evidence of solids carryover, evidence of-leakage into rout of box, etc,) .. ,K,1-1)4"1 PUMP CHAMBER:_ (locate on site plan) Pumps in working order.(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (rev]oed 11/03/9s) 7 06/10/1997 14:07 15084755101 PRU HOWE & DOHERTY E PAGE 09 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address;-5'YY C:��''i���''r- Aa^%dAr1e2 � 0/�S Ownet Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):,x (locate on site plan, if possible; excavation not required, but may be approximated by non-intrusive methods) If no determined to be present, explain: , U d r- iD•� o ur - - Type: leaching pits, number:_ leaching chambers, number: leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of oil, si ns of h dra lit failure, level of ponding, cpndition of vegetation,etc.) udt'ti v AX J41 CESSPOOLS: _ (locale 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:_ (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.) (revised 11/03/95) 8 06/10/1yy7 14:07 1501:34755101 PRO HOWE & DOHERTY E PAGE 10 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:Sy &-evo,z Ivu ,� Ownet�j"Q,171gV ZQ ���u, /•_ Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' { j �EA2 of ►5-�. i o "'e / 7` DEPTH TO GROUNDWATER Depth to groundwater: feet method of determination or approximation: (revised 11/03/95) 9 WELL DATABASE 9 ADDRESS: A AGE OF WET r WELL DRILLER: �r WELL PER�tiQT,T: WELL LOCATION: zoo 7 -SELL PERMIT DATE: DEPTH OF WELL: � TYPR OF WELL: a- DRILLED ? b. DUG c. UN�N0V -- TYPE OF WATT EEARING ROCK: T7 WATER ANA..LYSIS DATE= `? GH-�Z-14GANESE:. Y N HICHIRON: Y N OTEEIZCONTAM ANTS: Y WELL:DATA.BA-EE ADDRESS: y AGE OF WELL: � WELL DRILLER: � „•. .WELL PERMIT T: WELL LOCATIUN � V, WELL,PERMIT DATE: DEPTH OF WELL: TYPE OF WELL: a.. DRILLED ? b. DUG- c. UINK OWN TYPE OF WATER BEARING ROCK: 21 - WATER 1WATER ANALYSIS DATE: Z HIGH-MANGANESE: Y N HIGH IRON: Y N OTHER CONTAMINANTS: Y N r TOWN OF SYSTEM PUMPING RE ORD DATE '�-04 SYSTEM OWNER&ADDRESS SYSTEM LOCATION1�i' ( v (example:left front of house) cjal�� lAn . DATE OF PUMPING: i QUANTITY PUMPED : GALLONS CESSPOOL: NO S SEPTIC TANK: NO YES / NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACIIF'IELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.® Lowell Waste A T®wrN©F NORTH ANQ0VER� I B0,4RD 0, ,LTI f F I R S T HOME INSPECTIONS, INC. .._.a SAFETY Make safety your FIRST choice. �' i997 * 200 ELM STREET BRIDGEWATER,MASSACHUSETTS'02324 1-888-,5_ TY 4 1 888 723 3894 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: 5`/ dedOAV 'h`'"L• &0*464V4 ^-aVy_l'Address of Owner: Date of Inspection: 3-5-917 (If different) Name of Inspector.,7>j-p,0gjr4.y SE/OE'L- Company Name, Address and 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: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signature: Date: 3—11--11:717 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. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not. _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. (revised 11/03/95) �• irk Printed on Recycled Paper y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ! Property Address-0i;11p/gys- f Ownrr- arr�T.vK't �sR�a✓t� Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed d;soibution box is levelled or replaced s The system required pumping more thanwfour times a year due to broken or obstructed pipe(s). The system will pass inspection if(wit Wapproval'of•fhe Board�of`fl"ealth}:`' x : '• — - - - r . broken pipe(s) are replaced -- obstruction is removed ,a C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: r. 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. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALT44ND SAFETY AND THE ENVIRONMENT: _ Cesspool or privy\is withir�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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic!a.^.k and sci! absorption sy5;em and is within. a Zone I of a public supply wc!!. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a"well water analysis for coliform bacteria and-volatile orgariic 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. 3) OTHER (revised 11/03/95) 2 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:-5""/6L-l'.f XAAe- X67 A+ re, A% Owner—X' —y 4-Ti9.vCC �,2a�G�� 1 Date of Inspection: D] SYSTEM FAILS: I 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. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. :..�.-._ "PP sch' rge,or� ondmg of gffluent:to,the urface,oftheground or surface waters due to an overloaded or clogged SAS or cesspool. x-StaMicc liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. ...1 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 iswithin 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 I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. e 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. El LARGE SYSTEM FAILS: The following criteria apply to large systems in addition to the criteria above: The system serves a facility with a.ilesi ri`flow of 10000 d or rester(Late S`stem)and'the s"stem is a significant threat to Y Y g gp S g Y Y g public health and safety and the environment because one or more of the following conditions exist: 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. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 'E-Pe' �,QAiC~ //L A�4V4' Owner:-V8y-t d-.3aA,,eje VA�?Ojeq Date of Inspection: y Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of Health. } w • A .. g . None"of the'system components ha'3e been pumped for at"lea3t two weeks and fhefsystemyhas been receiwng'norma(ftow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. #—ff As built plans have been obtained and examined. Note if they are not available with N/A. ,r The facility or dwelling was inspected for signs of sewage back-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 existing information or approximated by non-intrusive methods. The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. • 4 ' (revised 11/03/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �,, / Al SYSTEM INFORMATION Property Address:-Sy a4*14e 1-i;. 4, A�- fi"ucx-11 Owner7a—^ e,.J�wli e. CRa�oq I' Date of Inspection: 3—s-� FLOW CONDITIONS RESIDENTIAL: r�-t. Design flow:P" gallons Number of bedrooms: 3 Number of current residents: Garbage grinder (yes or no):J✓O Laundry connected to system (yes or no): S Seasonal use (yes or no):A/D Water meter readings, if available: At �4011WA 4-r /111LQ df /U•�-� Last date of occyancy: COMMERCIAUILNDUSTRIAL: Type of establishment: Design flow: ` gallons/day 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: OTHER: (Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: (yes or no)&V If yes, volume pumped: ga!!ons Reason for pumping: TYPE OF SYSTEM Septic tank/distribution box/soil absorption system t. Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any). Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: ��.�.F,:t .i.� AT' Zw til- fi oN i Sewage odors detected when arriving at the site: (yes or no)A (revised 11/03/95) $ . s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:S 66:440„(�t,I,_- AOIAW,4�' /* e�/5os-- Owner: Date of Inspection: SEPTIC TANK:_ (locate on site plan) Depth below grade: Material of construction: X concrete _metal _FRP_ other(explain) Dimensions: g9k Sludge:depth:- Distance from'top'of sludge [bottom of outlet tee or'baffle: Scum thickness:_ Distance from top.of scum to top of outlet tee or baffle:_? Distance from bogom of scum to bottom of outlet tee or baffle: /G �• Comments: a (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, etc.) r ,C2. — /o..rto ou r1 r GREASE TRAP:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —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: 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, etc.) (revised 11/03/95) 6 !Y SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 'y —" �G, . Ownefc'�,-0"d-�19jlr��t !a�? 7400- Date of Inspection: 3-s`- 7 TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP _other(explain) ;i. �t;..,.. !]Imen510p5; ...r...t.. Capacity. gallons Design flow: gallons/day Alarm level: Comments: _4 (condition of inlet 0e, condition of alarm and float switches, etc.) DISTRIBUTION BOX:X (locate on site plan) Depth of liquid level above outlet invert: A i Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of.leakage into or out of box, etc.) C tc&- S.'/'yQ S .0 S Cr PUMP CHAMBER:_ (locate on site plan) A : r + �.°. i' S. f , ,,• ' ' Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) 5 f (revised 11/03/95) 7 t a i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: S'Y 6e5/�/1/1fA'e Owne /M-17 {t9fi/)+te_ Date of Inspection: 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: Le i Type: � leaching pits, number:_ ;l a leacliing(cham6ersnumbest :. i, .. w wd .. : ., . i leaching galleries, number t 1 t a �,t - 1 ar leaching,4renches, number,length: leaching4ie16, number, dimensions: •_. overflowacesspool, number. _ Comments: (note'bndition ofosoil,si ns of h dra lic failure, level of ponding, condition of vegetation,etc.) IF CESSPOOLS: _ (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.) i 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.) (revised 11/03/95) 8 l i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:Sy ar-A- it Ae,� 106, /� +lie>� � 01,9V - Owner-74m¢,7Awic.e Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' OF <46s-e. 1 1�i 3171 0 i 9' fie" P DEPTH TO GROUNDWATER Depth to groundwater:U"'kiO feet /J /� ) ,v method of determination or approximation: /�/O &4--#X-15 017 d,&OI'Gl'C'A16f revised 11/03/95) 9 Commonwealth of MassachusettsIVED _ City/Town of No. Andover a System Pumping Record JUL 181011 ,M Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forms HEALTH D PAT NT 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out 1. System Locatio ' cckLr Ln forms on the computer,use _ only the tab key A ress to move your No.Andover Ma 01845 cursor-do not City/Town State Zip Code use the return key. 2 System Owner' -Lrntab Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /000 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap '1 ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. stem Pumped By: r-hCd c1nl'l r CA.C) Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: C Wr ' reatment Plant, 20 So. Mill Bradford, Ma 01835 ln4zkzl r Date Sig eceiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1