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Miscellaneous - 53 SPRING HILL ROAD 4/30/2018 (2)
i 53 54?-;=M_ f ;zrmn _ d r � r , 4839 Cf MOPT.�� �! . O • Town of North Andover `a'•>,;:o : ` HEALTH DEPARTMENT ,SSACMUStt CHECK#: � � DATE: /D LOCATION: j/J r H/O NAME: 6 CONTRACTOR Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service-Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal(Septic)Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval $ ❑ Septic Disposal Works Construction(DWC) $ ❑ Septic Disposal Works Installers(DWI) $ ❑ Title sn pector $ itle 5 Report $ [� ❑ Other:(Indicate) $ ealth Agent Initials White-Applicant Yellow-Health Pink-Treasurer Commonwealth of Massachusetts RECEIVED Title 5 Official Inspection Form =- j, a Subsurface Sewage Disposal System Form-Not for Voluntary Assess �� 1 fi+Hlt 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/1 10 every page. City/Town State Zip Code to of inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out A. General Information forms on the computer,use 1. Inspector: only the tab key to move your Neil J. Bateson cursor-dq,not Name of Inspector use the return key. Bateson Enterprises Inc. Company Name 111 Argilla Road Company Address Andover Ma 01810 ram M City/Town State Zip Code 978-475-4786 SI15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 7/12/2010 Ins6ectoed/SignaturyDate The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts E Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. CitylTown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ❑ I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ® One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ® Y ❑ N ❑ ND(Explain below): Septic tank leaking out, liquid level at seam. t5ins•09108 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes(cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ® N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ® N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ® N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh ❑ P P vY 9 9 t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments . 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health(and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Septic tank leaking out&d-box leaking. D) System Failure Criteria Applicable to All Systems: You must indicate"Yes"or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than %day flow t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins•09/08 T&le 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityfrown State Zip Code Date of Inspection C. Checklist Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 600 t5ins•09/08 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information Description: .0 Number of current residents: 5 Does residence have a garbage grinder? ® Yes ❑ No Is laundry on a separate sewage system?[if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonaluse? ❑ Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (gP ))� Detail: Sump pump? ❑ Yes ® No Last date of occupancy: Current Date Commercial/Industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallonser day Y(gPd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: !Sins•09108Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form f Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): .q General Information Pumping Records: Source of information: Pumped 2009, owner Was system pumped as part of the inspection? ❑ Yes ® No If yes,volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed(if known)and source of information: 24 Years old, 7/17/1986, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): � Depth below grade: 3 feet Material of construction: ®cast iron ®40 PVC ❑ other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints,venting, evidence of leakage, etc.): 4"Cast iron thru wall , 3" PVC in house, no leaks visible Septic Tank(locate on site plan): Depth below grade: 2 feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: 10'x5'x4' Sludge depth: 1" l5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 9 of 17 1 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road f Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle N/A Scum thickness 1" Distance from top of scum to top of outlet tee or baffle N/A Distance from bottom of scum to bottom of outlet tee or baffle N/A Tank Leaking How were dimensions determined? Tape Measure Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.): Tank leaking, liquid level at seam. Tank needs to be replaced. 9 q P Grease Trap(locate on site plan): Depth below grade: feet 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: Date t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments I 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is North Andover Ma 01845 7/12/2010 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No l5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 Commonwealth of'Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened)(locate on site plan): Depth of liquid level above outlet invert -1" 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&distibution equal. Evidence of leakage, liquid level 1" below inverts.. Evidence of carryover, Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): Soil Absorption System (SAS)(locate on site plan, excavation not required): I If SAS not located, explain why: t5ins•09/08 Title 5 Official Inspection Foam:Subsurface Sewage Disposal System•Page 12 of 17 it Commonwealth of Massachusetts _ Title 5 Official Inspection Form a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments "< 53 Spring Hill Road Property Address Wendy Brandner Owner Owners Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ® leaching trenches number, length: 5 trenches 87' long ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetation ok. No sign of ponding to surface. Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•09/08 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately .y g A 3 o` t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form ' Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 'c 53 Spring Hill Road Property Address Wendy Brandner Owner Owner's Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ® Check Slope ® Surface water :a ® Check cellar ® Shallow wells 4 Estimated depth to high ground water. feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 7/12/1985 Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pit data on design plan. Before filing this Inspection Report,please see Report Completeness Checklist on next page. t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 53 Spring Hill Road P 9 Property Address Wendy Brandner Owner Owners Name information is required for North Andover Ma 01845 7/12/2010 every page. Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Summary Record Card generated on 6/30/2010 2:42:07 PM by Karen Hanlon Page 1 ' Town of North Andover Tax Map # 210-107.A-0243-0000.0 Parcel Id 18070 53 SPRING HILL ROAD BRANDNER, TIMOTHY BRANDNER, WENDY 53 SPRING HILL ROAD N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residentia Size Total 1 Acres FY 2010 UB Mailing Index Name/Address Type Loan Number Active/Inact. From Until BRANDNER,TIMOTHY Payor BRANDNER,WENDY 53 SPRING HILL ROAD N.ANDOVER,MA 01845 UB Accognt Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 14255.0-53 SPRING HILL ROAD Last Billing Date 6/2/2010 2100250 02 Cycle 02 Active UB Services Maint. Account No.2100250 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 72.20 /1 UB Meter Maintenance Account No.2100250 Serial No Status Location Brand Type Size YTD Cons 36207069 a Active ERT HH b Badger w Water 0.63 0.63 19 Date Reading Code Consumption Posted Date Variance 5/4/2010 27 a Actual 19 6/9/2010 16% 2/1/2010 8 a Actual 8 3/11/2010 -100% 12/18/2009 0 n New Meter 0 3/11/2010 -100% 12/18/2009 3553 r Replacement 8 3/11/2010 -48% 11/2/2009 3545 a Actual 30 12/11/2009 -23% 8/4/2009 3515 a Actual 40 9/11/2009 76% 5/4/2009 3475 a Actual 22 6/16/2009 2% 2/4/2009 3453 m Manual estimate 22 3/16/2009 -360/c MSG 11/5/2008 3431 a Actual 35 12/10/2008 -360/c 8/4/2008 3396 a Actual 55 9/12/2008 1570/c 5/2/2008 3341 a Actual 20 6/18/2008 -3% 2/4/2008 3321 a Actual 22 3/14/2008 -59% 11/2/2007 3299 a Actual 52 1/15/2008 -290/c 8/3/2007 3247 a Actual 73 9/14/2007 190% 5/4/2007 3174 a Actual 18 6/22/2007 35% 2/28/2007 3156 m Manual estimate 24 3/23/2007 -37°/a 11/3/2006 3132 a Actual 24 12/22/2006 -51 Trouble Code:03 8/21/2006 3108 a Actual 58 9/13/2006 150% Trouble Code:03 5/25/2006 3050 a Actual 28 6/20/2006 6% Trouble Code:03 2/8/2006 3022 a Actual 24 3/13/2006 -57% f i Commonwealth of Massachusetts W City/Town of No.Andover System Pumping Record �M Sye y`ev 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. RECE' S A. Facility Information Important: NOV 10 2011 When filling out 1. System Location: forms on the TOWN OF NORTH ANDOVER computer,use 1 HEALTH DEPARTMENT only the tab key Address to move your No.Andover Ma 01810 cursor-do not City/Town State Zip Code use the return key. 2. System Owner: r Name 'e a Address(if different from location) City/Town State Zip Code I Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons- 3. Type of system: ElCesspool(s) optic Tank E] Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. S stem Pumped B � Name Vehicle License Number Stewart's Septic Service Company 7. Locationre contents were disposed: w S i't's P`r-treatmqj3t Plant, 20 So. Mill Bradford, Ma 01835 _ I Signatu Date Signature of Recei ' g Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 i �kw}4.is :�Isy �T7 rri5, > x t : h`J Commonwealth of Mssachuse s City/Town of NORTH tt ANDOVER MASSACHUSETTS System .Pumping Record Form 4 I OCT 1 2 2006 DEP has provided this form for use b to I ' A\"-OVER be submitted to the local Board of Health or other approving authority. alth. The. stetn•Pinping Record mu: A. Facility Information - Important: When filling out 1. System Location: forms on the computer, use ,` only the tab key _..--- - o move your cursor•do not use the return City/Town '— -----=-- __ key. State Zip Code VQ2• System Owner; VQ �3 n Name Address(if different from ovation _ - a _ Cltyfl own State Zip Code - Telephone Number—B. Pumping Record .K 1. Date of Pumping Z 5 G6 Date -' 2. Quantity Pumped: 3. Type of system: ❑ GallonsCesspool(s) � eptic Tank El Tight Tank ❑ Other(describe): ------_._. 4. Effluent Tee Filter present? ❑ Yes [ If yes, was it cleaned? ❑ Yes ❑ No r 5. Condition of System: �y 101 6. Sy em Pumped By: -- . ams Vt, a Vehicle License Number' --' .company . %� , 7: Location where contents were disposed: S ature Of Hsu --. http://www,mas .gov/dep/water/ oats --"- --_------_-- -_—.----_ - proyals/t5forms.htm#inspect 15form4.doc-06/03 System Pumping Record•Page t of , TOWN OF NOR'T'H ANZDUVSk, UA t'k sYS7SM PUMPINQ R_ECopjl SYSTEM OWNER ADDRESS SYSTEM LOCAT1nN Qin `' . ot DATE OF PUMP(NQ: .�`,,.. _QUANTITY PUMPED; tSSPOOL: NO_... Y.Bg .. ... Snpiic 1'�nk: NU, YDS N�1 fUKE ON 3BRyICE: KO4�'f1NE _ i MmER( I~NC'1' UkbSLRV RECEIVED D �DITION FULL 'ry COVER OAVY© s8 BAFFLES IN PLACE, AUG 1 2 2005 ROOTS LEACKFIELD RUNBACK _ . 6XCESS7VE SOLIDS FLOODED . 10LIDCARRYOYER OTKER EXPLAIN _ T�HEALTHDEPARTMENTWN OF NORTH OER J�/'l)/CC CUMMENT3. l'VN!'EN'I'y rli�iNSr'lrRR1iD ru FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section*****************��l APPLICANT: �- l l t 1EZ_ Phone 41&9- ga 1 a LOCATION: Assessor's Map Number to Parcel -2- Subdivision Subdivision Lots) Street 53 St. Number ************************Official Use Only************************ RECOMMENDATIONS OF TOWN AGENTS: Date Approved Conservation Administrator Date Rejected Comments Date Approved Town Planner Date Rejected Comments Date Approved Food Inspector-Health Date Rejected v—� Date Approved /� Se t177C�Ins�pecto�r-He`alth��P Date Refected Comments Public Works - sewer/water connections - driveway permit Fire Department Received by Building Inspector Date -o I cn -z-, i� co cil w MORIuAGE INSPECTION APPIe ton Land Snrroayina, Ino. BU MING s IMMIEA06• mA P.AhNINj (aks==�SIRM, Mx XWr* W%SgA Mmc al"o � (aeysu..uaa MORIOMORn-4sm �8 ADDRESS flF PRINCIPAL SUMO kG -- q' �a �� __-�3 .�pECtNG iJ I..L. '7•uoArj wo prod t VSA d1 ja for my" per*" ad k I.oeenoi M V rYkd mu 4ap sad ra4am� `9 bf a? tw then be e*ld ftFt pa od b p� Ms n aonmoom sR>t �' la dd MMD'°p°pa mnt�oje Sawki e NN IhMraLk an BlsimoAm ks etbn �d npradueGonrnS6fbdSon�SLoft the miottod alerid b dddy ` plod.rlliin eonriM ,an A'St it oblelx! at" CU nKrAIM Rk _.VRsr%snr / se+�a 1Hs neeF�opr..ti'�"tb""°`�"Q°na F eaeeroapar �\yA *Ih tls 3r�l,r SlridorN to Lr=Som Ih- p�yxe a dud Sr.* saaoFlw4by Va 04 bVlt"rs k. baxhten I SWE W N ABY PHOF) mik oPtwx A 3 . L% Mwbor fr' rbuchrr�i Q /1 y� p +fPt IN&MA$Wd MrocA ***MaAS N ne fi 6 I �j eadnaeas,ord 1 O anfm Kereach o* �r9 too / l \61 aPVw kmft i*aWrb 04 No6d 1 �lv ■ kog is nd boatel v ft a Road Mram6 I0% / t) bfarineGon d InallkMdZ�ft— to as MN lbod Nmard f 9-9.93 \xe Ky�t iO Op"Neuenw. W 77 MD rl, rO Cent$ e1p Dd.dispsrlkrr tan Refcsncy fl Mw- .rf��88 Dds d v - 6s c �n i SEPt C -- _.w j 4 I r • i , ! � it ij I �i 1 t E NEW ENGLAND ENGINEERING SERVICES INC August 5, 1999 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: 53 Spring Hill Road,North Andover Enclosed isa copy of the Title V report for the above referenced property. The systemap sses our inspection. If there are any questions please call me at my office, 686-1768. Sincerely C Benjamin C. Os ood I,.T. g President RTH ANDOVER/ C,-HEALTH a AUG -a 1999 6 1 33 WALKER ROAD-SUITE 23-NORTH ANDOVER,MA 01845-(978)686-1768-(888)359-7645-FAX(978)685-1099 COMMONWEALTH OF MASSACHUSETTS � EKECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS r I L AE : DEPARTMENT OF ENVIRONMENTAL PROTECTION , 5 ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY CORE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Pr Address-5� SileINfT IJILL ��.I r(,Rr 4Wip R Name of Owner _114A( jl'JILt�/Z Property - p 'l /Q� Address of Owner: 5 3 S etzt NCr Hit �!�,,/Y• 1110-A✓k� Date of Inspection: 91�'I'/9 Name of Inspector:(Please Print) Benjamin C. Osgood, Jr 1 am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000) Company Name: New England Engineering Services_ Inc. MaAngAddress: 33 Walker Rd., � 1�re 23, Nnrt-h Andover, MA 01845 Telephone Number: 978-686-1768 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 _ Fai s Inspector's Signature: C Date: LA The System Inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)w'Ithin 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 oh£nvironmental Protection. The original should be sent to-" system owner and copies sent to the buyer,if applicable, and the approving authority. NOTES AND COMMENTS I rX. y I revised 9/2/98 Page Iof11 `i 1'nmed on Recyclyd I'au•' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:53 Spring Hill Rd.,N.Andover Owner:Joan Miller Date of Inspection:8/4/99 INSPECTION SUMMARY: Check A, B, C, Or D: A. .tY/STEM PASSES: 1( 1 have not found any information which indicates that any of thq failure conditions described in 310 CMR 15.303 exist. Any failure I 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. 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,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 inspection if the existing septic tank is replaced with a complying septic tank as approved by the Board of Health. _ 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 distribution box is levelled or replaced _ The system required pumpirig-more than four-times a yeardue to broken or obst, cted pipe(s)- The system will peas" inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed revised 9/2/98 Page 2ofII i CUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A Property Address:53 Spring Hill Rd.,N.Andover CERTIFICATION(continued) Owner:Joan Miller Date of Inspection:814/99 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 the public health, safety,and the environment. 11 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 WHICKYYILL.PRQTECT THE PUBLIC HEALTH AND SAFETY AND THE ETIVIRONMEXT: Cesspool or privy is within 50 feet of 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 AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. 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 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. Method used to determine distance (approximation not valid). 3) OTHER I revised 9/2/98 Page IofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:53 Spring Hill Rd.,N.Andover Owner:Joan Miller Date of Inspection:8/4/99 r D. SYSTEM FAILS: r t F s You must indicate either -Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what YMI be necessary to correct the failure. Yes No Backup of&ewage into4acility-or-sTsb—c component-due go an overloaded omlaggedSASar•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. E. LARGE SYSTEM FAILS: 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: 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-e4filmery-to-asur(aoad«nkir►g-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 upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII i r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address:53 Spring Hill Rd.,N.Andover. Owner:Joan Miller Date df Inspection:8/4/99 ! ! ! Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No f _ Pumping information was provided by the owner, occupant,or Board of Health. _✓ _ None of the system sompoosnU.h&va b&an pualpod tor-aKJesst two wookc and-the systam hasbrwaascuai09 em.K&l Slow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not available with NIA. _ 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 orr the site has been determined based on: / Existing information. For example, 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) 115.302(3)(b)I The facility owner(and.ocrupaots_if different from-mwner).were-prnmided.with iofouna ioILDn tha propw aintatsat�rav1 Subsurface Disposal Systems. II revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:53 Spring Hill Rd.,N.Andover Owner:Joan Miller Date of Inspection:8/4/99 FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms(design):_ Number of bedrooms(actual):J Total DESIGN flow Number of current residents:a Garbage grinder(yes or no):NLES Laundry(separate system) (yes or no):ND ; If yes, separate inspection required Laundry system inspected lyes or no) Seasonal use (yes or no): ND Water meter readings,if available (last two year's usage(gpd): T01,44 Sump Pump(yes or no): NO Lest date of occupancy:LQ91�yj COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( Based on 15.203) Basis of design flow 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) Lest date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: i?0o,PEn i so 9 co System pumped as part of inspection: (yes or no)--LjO If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM ✓ Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system(yes or no) (if yes, attach previous inspection records,ii any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components,date instaRed{if known)-and source of4Mormation: 1�Ft.(z AS -3ut�T Sews"odors detected when arriving at the site: (yes or no)I—A� i revised 9/2/98 1`2ge6ofll e1lBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C .SYSTEM INFORMATION(continued) Property Address:53 Spring Hill Rd.,N.Andover Owner:Joan Miller Date of Inspection:8/4/99 BUILDING SEWER: (Locate on site plan)- r F F Depth below grade:_ / Material of construction:V Cast iron_40 PVC_other(explain) Distance from private water supply well or suction line Ir Diameter _ Comments: (condition of joints,venting, evidence of leakage,etc.) Pori- IN �t,U1 Cot�01TIoN SEPTIC TANK:_ (locate on site plan) it Depth below grade:01f Material of construction: /concrete_metal_Fiberglass _Polyethylene_other(explain) If tank is metal,list age_ Is.age.confirmed by Certificate of Compliance_(Yes/No) Dimensions: I SO() CT.4LUON Sludge depth: .211 �r _ Distance from top of sludge to bottom of outlet tee orbaffle. Scum thickness: -4-1 r� �. r r ' Distance from top of scum to top of outlet tee or baffle: r Distance from bottom of scum to bottom of outlet tee or baffle: I How dimensions were determined: ✓►1C�ASV ei-- ST-I LK Comments: (recommendation for pumping,condition of inlet and outlet tees or-baffles. depth of liquid level in relation to outlet invert, structureHntegrity, evidence of leakage, etc.) T-/4,N r f N "O D Dopa D(T-)Clot . O C-tZ 9CT C T 5-V--S I N CrvO D CONp)rlol-1 1 I�ISiA LL- "1 01'1 OC= R (i= TU w iTit I N 6 f' (9F FINS[-r C ?=8�k GREASE TRAP:_ (locate on site plan) Depth below grade:_ Material of construction:_concrete_metal_Fiberglass _Polyethylene_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments: (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 9/2/98 Page 7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address:53 Spring Hill Rd.,N.Andover Owner:Joan Miller Date of Inspection:8/4/99 TIGHT OR HOLDING TANK:,Na (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 I Design flow: gallons/day Alarm present 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) 1/ Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — ' — &j )A 020P 000 DO70N V IST-P( 'xl n o,u Frd,-)A-L MQ r.✓(PLU CE !JF (_FAK-ocrF F�ooDthtC o(L Sf�� t� S Gi2j2�[OV�r - I PUMP CHAMBER-Ah (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.) J revised 9/2/98 Page 8ofII • �1 1 , 1 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C Property Address:53 Spring Hill Rd.,N.Andover SYSTEM,INFORMATION(continued) Owner:Joan Miller Date of Inspection:8/4/99 i SOIL ABSORPTION SYSTEM(SAS)— (locate on site plan,.if possible:excavation not required,location may be approximated by non-intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers,number:_ leaching galleries,number:_ _ leaching trenches,number,length:__2 leaching fields, number, dimensions: overflow cesspool,number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, damp soil,condition of vegetation, etc.) A42k-k oE 5ys; rtn Lo�t�s No . Nv IPouoruc,- I124YR Sores , 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.) PRIVY: NA (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation;etc.) revised 9/2/98 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART G SYSTEM INFORMATION(continued) ! Property Address:53 Spring Hill Rd.,N.Andover Owner:Joan Miller Date of Inspection:8/4/99 F SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks F locate all wells within 100" (Locate where public water supply comes into house) c i H0 15� �I ' 3005 39.E sa' t i f revised 9/2/98 P2 C 10ef II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:53 Spring Hill Rd.,N.Andover Owner:Joan Miller Date of Inspection:8/4/99 NRCS , Report name SOI WVIC'I Usk L om r-i n'Uf sd(a Vic 1775 5 8641WX riff% 11 Soil Type_ C RL—TV/4 j 7 F i Typical depth to groundwater > USdS Date website visited Observation Wells checked / Groundwater depth: Shallow Moderate Deep (/ SITE EXAM Slope 2-0/40 Surface water 100me Check Cellar NO wArtt Shallow wells KdNE Estimated Depth to Groundwater (P Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property,observation hole.basement sump etc.) Determined from local conditions Checked with local Board of health _Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) Z'J �.S.lT.1, ? i 1NDIcS w�A�r�az T,wbc ? J �itt o�tJ o�q ir-kiStlntC•T C9>>t_ .4i? 4 o� yS ir7 1-f+S RffiLf wt LLEn ONF- Fvci 1"D S 6 L9 i revised 9/2/98 Page 11 of II Commonwealth of Massachusetts Executive.Cffice of Environmental Affairs - Department of Environmental Protech®n MVilrm F.Weld Trud Cote Argeo Peal Celluccl y LL Governor Davld B.Struhs commbsloner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Addr,... .:5-,3 Ef;til/V G fid. �i OPa�i ko, �dovee,we;� Address of Owner. Date of Inspection (If different) Name of Inspector. Benjamin C. Osgood Jr. Company Name,Address and Telephone lJumber. New England Engineering Services, Inc. 33 Walker Road, North Andover, Ma .01845 CERTIFICATION STATEMENT Tel.. 508-686-1768 Fax. 508-685-10.9.9 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 systema.'The system: �Paases _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Signatures Date: The System Inspector shall submit a oop =imspection report to the Approving.Authority within thirty(30)days of completing this inspection. It the P m8 P eystein 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_- All ,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 yea, no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) _ The septidtank 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 )1/03/95) 1 One VAnter Street • Boston, Massachusetts 02108 • FAX(617)556-1048 • Telephone(617) 292-5W Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A.- CERTIFICATION .-CERTIFICATION.(oontinued) Property Addrew 5�3 eel iLG;�G C e4i N 0 17x1�C74CtC�'!r1�X 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 pipes) , 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(a)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 S 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,the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOTFUNCTIONING 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'ofa 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 PROTECT 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 tank afld'soil absorption system and is within a Zone I of a public water supply well. The system has aseptic,tank and soil absorption system and.is within 50 feet of a private water supply well. The system has aseptic 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 organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogdn and nitrate nitrogen is equal to or less than 5 ppm., %4='3) OTHER . (reJiSed .11/03/95) 2 . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION.(continued) Property Address: Owner. S hqP� 2 v Date of Inspection: bY 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. 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, less ta6"belowurvert or available volume is lase than 12 day depth in cesspool lis hn : 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 60 feet of a'private water supply well. Any portion of'a cesspool or privy is less'than 100 feet but,greater than 60 feet from a private water supply well with no acceptable ester 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. 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: 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 11103/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B r CHECKLIST Property Address. Owner Date of Inmpootiom Check if the following have been done: 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,tlow rates during that period. Large volumes of water have not been introduced into the system recently,oras part of this inspection. �As built plans have been obtained and examined. Note if they are not available.with N/A. ✓The facility or dwelling was inspected for signs of sewage back-up. vThe system does not receive non-sanitary or industrial waste flow ZThe.site was inspected for signs of breakout. - '"All,system components,excluding the Soil'Absorption System, have been located on the site. vThe 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. Thefacility owner(and occupants,if diff'er`ent from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 SUBSURFACE SEWAGE,DISPOSAL SYSTEM INSPECTION FORM PART C- SYSTEM INFORMATION Property Ad areae: ,5 3 ink Owner Date of Inspection f�c 7 A o io FLOW CONDITIONS RESMEN'TIAI:: Design flow:. __.Ballons Number of bedrooms:,_ Number of current residents: Garbage grinder(yes or no): Laundry connected to system.(yes or no): Seasonal useo (Pea r no): , Lo, r^-- Water meter readings,.if availabl • 0� 9- `� 0 w Last date of occupancy: c cleew COMMERCIAL/IND USTRIAL Type of establishment: Des flow:�4 gallons/day Grease trap present: (yes or no)� Industrial Waste Holding.Tank.present: (yes or no) Non-. crani waste discharged to t e tai9 h .Tl 1 5 m: es or no Water meter readings, if available: Last date of occupancy: OTHER(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING-RECORDS and souree of information: i K �v►n P20 `� /ms s q G-y con eei .� �ucrz� System Pumped as Part of inspection:'(yes:of no) If yes, volume pumped: 2U_gallons :Reason for.Pumping TYPE OF SYSTEM ---;Septic tank/distribution box/soil absorption system Singie cesspool Overflow cesspool Privy . . shared system(yea or no) (if yes, attach previousinspection records, if any) Other.(explain) APPROXIMATE AGE of all components, date installed(if known)and source of information: Sewage odors detected when arriving at the site: (yes or no)�0 (revised :11/03/95) 5 SUBSURFACE SEWAGE DISPOSAU SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION (continued) Property Addces S3 S i el Owner. . S�i4Pi�,4. Date Of Inspection SEPTIC TANX- (locate on.site'plan) Depth below grade-.,;? Material of construction:_concrete._metal_,FRP _other(ezpWin) / 0U 4. - Dimensions: /0:x S' X S Sludge depth: Distance from top of slu i dge to bottom of outlet tae or baflle._Q?7 Scum thickness: ®. Distance from to of scum to to of outlet e tee or e: P balTl P . _ a D. �atance tiro m bottom of scum to bottom of outlet tee or bafIIe: Ire 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.) 71-,4" 6i-y0 p 00�e,f7 ' i`Uv, {, L,'d v D �-u r0-C S hg-t 419 T�t1 eu�G a Tv G,e.AorL vty s ��sS av�•2 d-S GREASE TRAP - (locate on site plan) Depth below grade: Material of construction: concrete metal_FRP�other(explain) Dimensions: Scum thicimesa: Diittance from top of scum to top of outlet tee or baffle: Disiance from bottom of:scum to bottom of outlet tee or battle: Comments: (recommendation for pumping;condition of inlet and outlet tees or baffles;depth of liquid level in relation to outlet invert, atruatural integrity, evidence of leakage,etc.) r . • (revised 11/03/95) 6 �� _3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property`Addresa 3 Pei`vli Gr d� . L Owner. e U Dste of Inspection ;,"TIGHT OA HOLDIN(I TANK (locate on site plan) Depth below grade: Material of construction: concrete, metal_FRP�other(e:plain) Dimensions: Capacity: aallona Design flow: "� allons/day Alarm level: .,. ,:Comments: (condition of inlet tee, condition of alarm,and float switches, etc,) D.XSTRIBUTION BOX: (locate on site.:plan) Depth of liquid level above outlet invert: 0 C6mment8:. (note if level.and distribution is equal, evidence of solids carryover,.evidence of leakage into or out of box, etc.) c p-n-fv w p.,C,zv c v e o e Le 4 k 4 e-,t Coe PUMP CHAMBER- (loc:ate on site plan). Pumps in working order:(yes or no) Comments.` (note condition of pump chamber, condition of pumps,and appurtenances,etc.) (revised 11%03/95) 7 9 - a SUBSURFACE SEWAGE DISPOSAI,,SYSTEM.INBPECTION FORM PART C. SYSTEM INFORMATION(continued) Property Addres� 0 t9 p :0�40U-ee VV, 4- Owner. S►�A P;.�e�. Date"of Inbpection ., .. SOIL ABSORPTION SYSTEM (SAS):_ (locate on sits plan, if possible;excavation not requir4,but may be approximated by non-intrusive:methods) If not determined to be present explain Type - • leaching pita;number leachm8 chambers, number: leaching galleries, number: _ leaching trenches, number,leagth: — �� l •fiG ]� 0P e ti I leaching fields,number, ^� dimensions: overflow oesapool,number: Comments (note condition of soil, signs of hydraulic.Wure level of ponding, condition of vegetation etc.) ��'J /2Vi1)l�2NGlz O IzvOC°ffyL,'G 'F/f�CIi+Pi�C ✓( G/��9�__= i S ��t `fcurzw� CE89I 0I;3: (locate.on site plan) Number and.configurationi Depth-top,of liquid to inlet invert: Depth"of solids layer. Depth"of scum,layer Dimensions of cesspool: Materials'of construction: Indication of groundwater: MOW(cesspool must be pumped as part of inspection) Coaiinenta. (note condition of soil signs of hydraulic failure, level of Ponding, condition of vegetation, etc.) PRI VX (locate.on site plan) Materials of construction of soDimensions Deptl . "i Comments: (note condition of soil,signs of hydraulic failure,level of ponding, condition of vegetation, etc.) (revised'11/03/95) 8 SUBSURFACE SEWAGE DISPOSAL'SYSTEM INSPECTIQN FORM PART, C SYSTEM INFORMATION(continued) 'Pilo s6- {jee.., YA 4 Owner: S h AG Date Of Inspection. a: SKETCH`.OF BEWA(IE DISPOSAL SYSTEM: include,ties to at.least two permanent references landmarki or benchmarks locate all wells within.100 I � ,� o,- _ DEPTH TO GROUNDWATER r 1 I)e i� feet dwatori , met)sod of determination or.approximation: (revised 11/03/95) 8 C BOARD OF kiEALTH No.Andover, Mass . SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT # 205MOGH1U..& APPROVED DATE 1 (- Z)-S 5 DISAPPROVED DATE, Provided: Reasons: j Title VF AILOK Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #,abutters b location and log deep observation hoes-distance 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 '(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 100' of sewage disposal system or disclaimer-Planning Board files _. (3) known sources of water supply within 2001 of sewage disposal a system or disclainer (k) location of any proposed well to serve lot-1001 from leaching facility (1) location of water lines on property-101 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 basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer or other M professional authorized by law to prepare such plans Reg 6 Septic tep is Tanks (a) capacities-15U of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 10, from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) —slope greater than 0.08 Reg �0.4 (b) s , r w .A d SubsiVsface Desi Check List Page 2 �*- FA31 CK Leaching Pita Leaching pits are preferred where the installation is possible I4 ' Reg 1:1.2 a) calculations of leaching area-mdnimam 500 sq ft 11.4 b) spacing 1110 c) surface drainage 2% 11.11 d) cover material e) g'x2 1 x4" splash pad f) tee at elbow g) no bends in pipe from d-box to pipe Leaching Fields Reg 15.1 a) no greater than 20 minutes/inch b) area-minimum 900 eq ft 15.4 c) construction of field 15.8 d) surface drainage 2 % 3.7 e) 201 from cellar mall or inground swimming pool Leaching Wenches Reg 14.1 a) cal.cura on�i s leaching area-min 500 sq ft 14.3 b) spacing-4 ft coin 6 ft with reserve between 14.4 (c) dimensions 14.6 d) construction 14.7 e) stone 1h.10 f) surface drainage 2% Downhill Slo e a) she y x = (to be shown) b) y/x x 150 - (to be shown) 9 Reg 9.1 a) approval al 9.6 b) stand-by power 5 PRv�1GHuc. z zc� I Cf.1 IT 3'i t5 L Sita FikC-54)-)n w7 ' _ -S' j +J I E; I I i I t P-wb of HFA i i-1 �-cT �-70 S'I RYJ(,mL-L K fl Nol�T'H /JvI�OUE��, NIQ. �BP�� C*J l (•�..��c��Pf'(.7_��T6W�J ❑ WEc..t_ AP�ouCD lYJT'C S5 l-70 SERr►c G- S iE.�t slc-• 1JPizoUw6 Aurr-Ioi�ITy -:fo/JJITi ays DI SAPPRpVED �/�T E R�QSoNS D� l ? � St�-I c SySTE�t 1�5�"A l..L,QTioiU �`YIIU/JT(C►IJ )NSf'E6►(p,v5S F41L �+ o>= P�-QNS PINAL l,U5Ri---poA) 4PPROOEP Quc- - 6W AWTIOMAL. 1)Q5Fbc1(oti5 SIF-A►�Y� DtSAPr��Dv�l� D,a i C R�,50 NS FML /JPPI?OVAL D,o�� TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD 9//sx-�z, � l STE'y1 OWNER & ADDRESS SYSTEM LOCATION (exam�le: left front of House) 46(K� ri U \"l E OF PUMPINC:4?`20`0'Z-- QUANTITY PUMPED/5�C'ALLO'�') I>OUL: NO /YES SEPTIC TANK; NO YES '.ATURE OF SERVICE: ROUTINE L'11--<m ERG EN CY U (3>ERV:\TIONS: GOOD CONDITION FULL TO COVER HEAVY CREASE BAFFLES IN PLACE P/ ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER Oj�HER (EXPLAIN) 7 PUMPED BY: i U 1I M ENTS: UN'I L'NT1 `I'IZANSFEIZIZEDTO: i pSg0V / G��R,C?E H TOWN OF NOR . ANDOVER , 2 r SYSTEM PU ING RECORD ��`� DATE e? (��/ 1 SYSTEM OWNER&ADDRESS SYSTEM LOCATION ,,, riw 117 e� Foy �.A? o DATE OF PUMPING: _$ QUANTITY PUMPED: 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 SOLID CARRYOVER OTHER EXPLAIN System Pumped by c,?o, COMMENTS: f I CONTENTS TRANSFERRED TO � '• W t I�OVERT:MASSACHUSETTS 00' •�'3,Jl4�t:� Q y r J�R'!i4�y(•Y<(�'�11,-• �slir�:;)u,vrv• .. '.•f•r ..�.fi:t..�5 Y+ry�p"'�''r2Q,,�l,�j"SI%j�Yv}y �� ,.;i7 �+�"'d;'' �' ,;. � , t�l�',Yt,gi•j,«f. l.f, irllr,'at•��,.•!•�•F"�•:tH'v�v(.I.Y.r�,.'.,•':'.r•. ':` •,�, .. DER his prcMded rhi' 'form for use by local Boards of Health be subtitled to the.locs1'BoArd of Health or other s 'the sYto ' mirig ecord must :».:;r 't{J!!'•i!\;;`,`G?;t,:b?:. '?\+f; r.5"':. PproVing`auth�rl!r EVEU A Facllity.,lnfq�t' ci lon ` SEP �f 7 ;?'•�tlY1OrLirlt: l' 1;; .J:,; 'Y:,; �,'.(:,y.,r,•,` 1 2001 j tour out 1,.:,, System,location;: ', H ANDOVER :�yti, � i ,:• ;i,:.. ,,. .,�:. �- ,ANN OF Na a •GOA1pUtOl�'y�z;�: `. _ F IST R T o.*the tab;key MUM* . ' to move your':: ,.cuRor•do tit;,:..:. :.. .. :.: .. r �%/S�l •'� �uie�thefOturl'1�y:.'',":�a'•.'C��OW�1 ? .a;' • .,•.,, .,: . •r .'. .. StatO �; t:,kl ,,�.�,� ;',ti:;,4i,t'ri,.,>:• .,..,i:,i' Zip Code' +1:•$ tate r ,,�rr,L J . s•• m Owner, �:k'rr•' `4}G �i�a:!l,fp.,rttr�l,y�;Ar!t,•+I • •:�`:•n a• � ,Y ll. J t`.k,itp��S"M�y�`J ,5•'S,,•'�,••\'�2,. t4 A it''J.,r\.�J•Y Na111� ' II.S:\•l 1.• 11 i +P,I:•l,..V;�,�•^. ,1 /:t .,q; 1••• .,�fi\,.r1r.,b7'i.}.;tjr,ttliit i.,�• ,ii:r •` '.... '�.9y.lq,;.•.,�%,�t'r,Yl,lrrr.4,r'p4�'�'�'�.`•.'ayi��;'..;-' ' ';'. �/!/!/ ®( ' "`", r%Address(If different rom bcatlon) 3,krrowm:.s..: Stats �ip Telephone Number t',. �, .r.'r'.u.r7'IJ/. �,r'!,:1,\':'yta '• :I.V,I•i:^�ts.:'.,J'rv, .,.� .. ,J•' .i:: }'�..:1+}•.,lr lel tY'�••t l�"'i.' .:i.•::r•�' Y..••':�i: .. .. ;Putn, �.,::'!�;,r.:i f;«4'`N'`F�'1''f'rr;2 rri,?(+b,i:a9'�J'V{I'�!,�L`�•i�ll•:�•' . •. ' ',.•...{�.{:.'I%,+,1,tit'• ,,pJ,:• yp '� „•i r',,. t.• /J /��� • [��• ''M,.:';li:J,..,.� lei'{+$. a '4':7R,;ifx•bc}L}: ,'•r ,./ �.✓ 1, Dat O Pumping Da 2. Quantity Pump GaAons fyps pf system,'.., ,,' ' ❑ Cesspool(s) �] Septic Tank ❑ Tight Tank Other(descrlbe)i:a ' :•,, '•!� .,..•�' •" +'1'i�tE�,1:V'i r,�,�'i,r S`!.�:I,1'i'JN�Y,jl�;p<:,tJ 3�• .. 5.,, .. .:�.`:.•, „• ,. '...Y. .l,jl:i•,,r.JI"•f.:'Iv'i is ''' •: E uent Ti Filte{,prt3sant?:.[] Yes o r If yes, was It cleaned? ❑ , �, :,' ::,,:>,:• Yes ❑ No a•. ;y:,. '"r`.rr,',r•. Aq.,:!,i�,.\ ,rpt'",,'il::'ay}'' e�}b 1. i;'i'i, ' 6,. 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'; ate httpJ/www,masa,goV/dep!watoe% pprovaJslt6forms,htm#Inspect �fOml�.d0a:t�lOS <' System Pumping Record Page 1 of, i n'/ C ' RT I ANDOVER; r�1ASS-ACHUS,F m n� Reco'rd {'`�<iYr �fy�,�', OCT - 9 2008 ^o P ha+ provided ihliYiorrn r^ vl1,!{10 0 the 10. Facillry Iniornia ;c •�� II/.vii l! Clr(�Vr'II .. , L+; ,f 2• Sys;am owner, :. . . t • r. AOdrei� (i(dV(�r�nl rcm buucn: ` c "Pumpin9 Regord 1 f XPQ v( 0X)(aM: T ell ( ) G: Ef van! Tao Flkl ( pQraaonr? �s f .', � 't,� •`i�` fir,:l r r — -.. I . �A ,f-`'G VO�IG'9 ',1 d •�( YY � � /rte •�';. .,`�:"%�1,1:A. IiJifr''��'d,,7'�fi'Jr11,'�'.1;t1'.��'/r'. �oca cn �,'n nls t l 1 r� ova)sllblorm9 a -C\ Commonwealth of Massachusetts City/Town of NORTH ANDOVER MASSACHSEMVD System Pumping Record Form 4 � ti DEP has provided this form for use bk local Boards of Health. The Sys e1$ pV AND VER be submitted to the local Board of Health or other approving authority. A. Facility Information Important: When filling out 1. System Locate : forms on the computer,use n Q only the tab key Address h to move your cursor-do not use the return City/Town State Zip Code key. 2. System Owner, r) Name s " A°D Address(if different from location) City/Town State, Zip Code Telephone Number ., -B. Pumping Record - �` _ �" _ _ _ ��_. }}�� qla 7_/1 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. ,Type of system: ❑ Cesspool(s) VSeptic Tank ❑ Tight Tank ] Other(describe): t 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes,`was it cleaned? ❑.Yes ❑ No 5. Condition of System: Q' 0Wj 6. S stem Pumped By: ( .. metkrj � ^ Vehicle License Number �Woua \Company ►Y�! 7. Aocatior here contents were dispose . ig t e of Hauler Date http://www.mass.gov/ p/water/approvals/t5forms.htm#inspect I t5form4.doc-06/03 System Pumping Record•Page 1 of 1