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North Andover Board of Assessors Public Access Page 1 of 1
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Return io the Home page click on logo a Record Card
Parcel ID:210/107.13-0086-0000.0 Community: North Andover
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Summary
Residence
Detached Structure
Condo
Commercial
Comparable Sales
64 OLO CART WAV
Location: 54 OLD CART WAY
Owner Name: HENRY,MICHAEL G
BARBARA J HENRY
Owner Address: 54 OLD CART WAY
City:NORTH ANDOVER State: MA 'LIP:01845
Neighborhood:8-8 Land Area: 1.12 acres
Use Code: 101 -SNCL-FAM-RES Total Finished Area:3312 sqft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 729,400 760,600
Building Value: 501,500 520,900
Land Value: 227,900 239,700
Market Land Value:227,900
Chapter band Value:
LATESTSALE
Sale Price:375,000 Sale Date:07/31/1989
Arms Length Sale Code:Y-YES-VALID Grantor:OLD MILL CONSTRUCTIO
Cert Doc: Book:02974 Page:0023
http://csc-ma.us/NandoverPubAcc/jsp/Home.jsp?Page=3&Linkld=1182060 3/10/2008
Commonwealth of Massachusetts rRE-CEIVIED
City/Town of
System Pumping Record L 012013
Form 4
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. ultner torms 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 housO�a right o
ou
Right side of building, Left/Right front of building, Left/Right rear of building, Under deck
Address C^ �
Cityrrown State Trp Code
2. System Owner.
Name
Address(if different from location)
Cityfrown7
State, ( ZiP' L
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped:
Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditio of st aZ:_ _ e J V-\ .��
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company .
7. jSigne
4Haule
ntents were disposed:
Lowell Waste Water
phi�� - --a � - (3
Date
t5form4.doc•06103 System Pumping Record•Page 1 of 1
NO R TFt
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PUBLIC HEALTH DEPARTMENT
Community Development Division
,rCFRT FICAr1-(F OE C09Y'( )(- T UME
As of:
March 15, 2008
(This is to cert that the individual su6surface disposalsystem received a
SAg1STAC TRT 1NS(PEM0X 0f the:
&T&cement of a Component:
0istri6ution Box Outlet Tee
Foran On Site Sewage �DisposaCSy�
By.
ToddBateson
At:
54 Old Cart Nay
31 ap-107.B; Parcel— 0066
Worth Andover, WA 01845
The Issuance of this certcate shall not 6e construed as a guarantee that the system will
function satisfactorily.
'Aus `Y. Sawyer
(Pu6Cu-.7fealth(Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 978.688.9540 Fax 978.688.8416 Web www.townofnorthandover.com
NORTF4
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SSAC HUS��
PUBLIC HEALTH DEPARTMENT
Community Development Division
CE 1�2I tUI C.A�I� O F CONI�G IANCE
As of:
March 15, 2008
'This is to cert that the individua(su6surface disposafsystem received a
SATIS FACTO1RT INST EMON of the:
ftfitcement of a Component:
of stri6ution Box eZ Out&t Zee
For an On Site Sewage gxwsa[System
0y.
ToddBateson
At:
54 Old Cart Way
Map-107.0; c'arcef— 0066
North Andover, WA 01845
die Issuance of this certificate shad not 6e construed as a guarantee that the system wia
function satisfactoriCy.
i
X16, 7 Saurye ,' /
Fu6fic Ifeafth Director
1600 Osgood Street,North Andover,Massachusetts 01845
Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com
l
TOWN OF NORTH ANDOVER
µORT1i
Office of COMMUNITY DEVELOPMENT AND SERVICES 3? '` ° ° °�
HEALTH DEPARTMENT • _.
1600 OSGOOD STREET; Building 2-36 '• "«»
NORTH ANDOVER, MASSACHUSETTS 01845 �9sS�cNu5Et4h
Susan Y. Sawyer, REHS/RS 978.688.9540—Phone
Public Health Director 978.688.8476 -FAX
ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES
LOCATION INFORMATION
ADDRESS: q.�l MAP: LOT:
INSTALLER:
v DESIGNER:
PLAN DATE:
BOH APPROVAL DATE ON PLAN:
\ INSPECTIONS �o�G ��U'•CGT�
\ TANK INSPECTION:
DATE OF BED BOTTOM INSPECTION:
DATE OF FINAL CONSTRUCTION INSPECTION:
DATE OF FINAL GRADE INSPECTION:
c�
SITE CONDITIONS
❑Existing septic tank properly abandoned
❑Internal plumbing all to one building sewer
Comments: ❑Topography not appreciably altered
v SEPTIC TANK
(�\ ❑ Bottom of tank hole has 6" stone base
�1 ❑ Weep hole plugged
❑ 1500 gallon tank has been installed
H-10 loading Monolithic construction
❑ Water tightness of tank has been achieved
(Visual or Vacuum Test or Water held for 24hrs)
❑ Inlet tee installed, centered under access port
❑ Outlet tee (gas baffle or effluent filter) installed,
centered under access port
❑ 24" inch cover to within 6" of final grade installed over
one access port, must be over outlet of tank if effluent
filter is present
❑ Hydraulic cement around inlet & outlet
Wastewater System Documentation—Feb 2006
Page 1 of 6
TOWN OF NORTH ANDOVER f N°RTH
Office of COMMUNITY DEVELOPMENT AND SERVICES
HEALTH DEPARTMENT A
1600 OSGOOD STREET; Building 2-36
NORTH ANDOVER, MASSACHUSETTS 01845F
-5
SACNU
Susan Y. Sawver,REHS/RS 978.688.9540-Phone
Public Health Director 978.688.8476-FAX
D-BOX
Installed on stable stone base
[✓]� Inlet tee (if pumped or >0.08'/foot)
Hydraulic cement around inlet & outlets
Observed even distribution ,
❑
Comments: Speed levelers provided (not required) = ,
SOIL ABSORPTION SYSTEM
❑ Bottom of SAS excavated down to soil layer, as
provided on plan
❑ Size of SAS excavated as per plan
❑ Title 5 sand installed, if specified on plan
❑ 3/4-1 Y2" double washed stone installed
❑
1/8-1/2" (peastone) double washed stone installed
❑ Laterals installed and ends connected to header
❑ Laterals vented if impervious material above
❑ Orifices @ 5 & 7 o'clock positions
❑ Gravel-less disposal systems: type, number and
location as per plan
❑ Elevations of laterals installed as on approved plan
❑ 40 Mil HDPE barrier installed
❑ Retaining wall (boulder/ concrete /timber/ block)
❑
Comments: Final cover as per plan
Wastewater System Documentation—Feb 2006
Page 3 of 6
0"°o'"Ah Commonwealth of Massachusetts Map-Block-Lot
�: 107.6-0086-
Board of Health
Permit No
= + North Andover BHP-2008-0012
+ P.I. -----------------_-
�S • FEE
SAC wus�� F.I. $125.00
-----------------------
Disposal Works Construction Permit
Permission is hereby granted Todd Bateson
------------------------------------- ------------------- - ------------------------------------------
to(Repair)an Individual Sewage Disposal System.
at No 54 OLD CART WAY
--------------------
-- - ------- -------------------------------------------------------------
as shown on the application for Disposal Works Construction Permit No. BHP-2008-001 Dated March 03,2008
--------------
------------------------------
Issued On: Mar-03-2008 ------------ ------- ------- ---
--- ---- ----------- Board of Health
KORA+.
O'...•o ..�a° Commonwealth of Massachusetts Map-Block-Lot
Board of Health -107.6-
-- --- -0086- ---------
+ North Andover
Certificate of Compliance
S4cwuse
THIS IS TO CERTIFY,That the Individual Sewage Disposal System (Repair)
by Todd Bateson
Installer
----------------------------
at No 54 OLD CART WAY
------------------------------ --------------------------------- - - --
has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the
application for Disposal Works Construction Permit No. BHP-2008-001 Dated March 03,2008
-- - ---- ---- --- -----
Printed On: Mar-03-2008
-- --- ------ Board of Health
3,139
Andover
Town of North DEPART
HEALTH
�ss�cMuse /
DATE:
CHECK
LOCATION:
H/O NAME: — / /�f�''�
CONTRACTOR NAME:
T a of Permit or License:(Check box) $-
❑ Animal $-
❑ Body Art Establishment $-
❑ Body Art Practitioner $-
❑ Dumpster $-
❑ Food Service-Type: $-
❑ Funeral Directors $-
❑ Massage Establishment $-
❑ Massage Practice $-
(Septic)Hauler
C3 offal(Sep
❑ Recreational Camp $-
❑ Sun tanning
❑ Swimming Pool $�
❑ Tobacco $�
❑ Trash/Solid Waste Hauler $-
❑ Well Construction
SEPTIC S�stems: $-
❑ Septic-Soil Testing $-
❑ Septic-Design Approval
i0" septi Disposal o ks Construe tion(UWC) $--
,���s oral►'Yorks nstaliers(DI
❑ Septic" J $�
❑ Title 5 Inspector
❑ Title 5 Report
❑ Other. (Indicate)
Health Agent Initials
Yelp
Health Pink-Treasurer
White-Applicant
'.rOR7M 1 A6plication for Septic Disposal System
O ee;• .{.�
�� �� „r_ - .,• o� TODAY'S DATE
pConstruction Permit - TOS OF
O $ 225.00-Full Repair
RTH ANDOVER MA 01845
,y •,eAne,,.: - $125.00 -Component
,SSwclmw
Important: Application is hereby made for a permit to:
When filling out ❑ Construct a new on-site sewage disposal system*
forms on the
computer,use ❑Zpa"iror
r replace an existing on-site sewage disposal system*
only the tab key G
to move your replace an existing system component-What? "' Q X �-
cursor-do not
use the return A. Facility Information
key.
ILEI Address or Lot# 7_— V
City/Town 'ld - frEB �+ '7 ZOH
2.-*TYPE OF SEPTIC SYSTEM": f
❑ Pump ❑ Gravity (choose one) TOWN of ntoRPARTDo TER
LTH D.
***If pump system, attach copy of electrical permit to applic ti.
❑ Conventional System (pipe and stone system)
❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system.
❑ Pressure Distribution S.A.S. (No D-Box) (Attach Draft Maintenance Agreement)
❑ Pressure Dosed (D-Box Present) S.A.S.
2. Owner Information
Name C?f� C.� P-�`✓/r
Address(if different from above)
CI Gown State Zip Code
RS' '�l0
Telephone Number
3. Installer Information
Name Name of Company
Address
Cityrrown State Zip Code
Telephone Number(Cell Phone#if possible please)
4. Designer Information
Nam4---
ddress Name of Company
A
CityState Zip Code
-
Telephone Number(Best#to Reach)
Application for Disposal System Construction Permit•Page 1 of 2
a NO.RT14 AOplichtion for Septic Disposal System
-Construction Permit - TOWN OF TODAY'S DATE
. w
ORTH ANDOVER MA 01845 $250.00-Full Repair
�.�'•,.,o..`n $125.00 -Component
SSwC1W`'E�
PAGE 2OF2
A. Facility Information continued....
s. Type of Building: esidential Dwelling or❑Commercial
B. Agreement
The undersigned agrees to ensure the construction and maintenance of the afore-described
on-site sewage disposal system in accordance with the provisions of Title 5 of the
Environmental Code, as well as the Local Subsurface Disposal Regulations for the Town of
North Andover, and not to place the system in operation until a Certificate of Compliance has
been issue y this Board of Health.
Nam Date
Applicatio Approved y: (Board of Health Representative)
_ _ DS
Na e � Date
Appli ation Disapproved or the following reasons:
For Office Use Only:
L Fee Attached. Yes No
2. Project Manager Ob . ation Form Attached.? Yes � No
3. Pump Svstem? If so,Attach copy of Electrical Permit Yes / No
4. Foundation As-Built. (new construction ronly): Yes No
(Same scale as approved plan)
5. Floor Plans?(new construction only): Yes No
Application for Disposal System Construction Permit•Page 2 of 2
.. SEPTIC SYSTEM INSTALLER PROJECT MANAGEMENT OBLIGATIONS
As the North Andover licensed installer for the construction for the septic system for the property at:
��l oldl CA�� �✓�*y
(address of septic sestetn) For plans by
,() �n sneer)
Relative to the application of �y u'"` �"P�O�
(Installer's name) and dated
ngtna ate
Dated — — Q
n ac s ate With revisions dated
(bast re-6sed date)
I understand the following obligations for management of this project:
1. As the installer, I am obligated to obtain all permits and Board of Health approved plans prior to
performing any work on a site. I must have the approved dans and the permit on site when any work is
being done.
2. As the installer, I must call for any and all inspections. If homeowner,contractor,project manager,or any
other person not associated with my company schedules an inspection and the system is not ready, then
item three shall be applicable.
3. As the installer,I am required to have the necessary work completed prior to the applicable inspections as
indicated below. I understand that requesting an inspection without completion of the items in accordance
with Title 5 and the Board of Health Regulations may result in a$50.00 fine being levied against me and/or
my company.
a. Bottom of Bed—Generally, this is the first (1'� inspection unless there is a retaining wall,which
should be done first. The installer must request the inspection but does not have to be present.
b. Final Construction Inspection—Engineer must first do their inspection for elevations, ties,etc.
As-built of verbal OK (or e-mail to: healthdept(aitownofnorthandover.com) from the engineer must
be submitted to the Board of Health,after which installer calls for an inspection time. Installer must
be present for this inspection. With a pump system,all electrical work must be ready and able to
cause pump to work and alarm to function.
c. Final Grade—Installer must request inspection when all grading is complete. Installer does not
have to be on-site.
4. As the installer, I understand that only I may perform the work (other than.ample excavation)and I am required
to complete the installation of the system identified in the attached application for installation. I further
understand that work done by others unlicensed to install septic systems in North Andover can constitute
reasons for denial of the system and/or revocation or suspension of my license to operate in the Town of
North Andover, significant fines to all ersons involved are also possible.
5. As the installer, I understand that I must be on-site during the performance of the following construction
steps:
a. Determination that the proper elevation of the excavation has been reacbed.
b. Inspection of the sand and stone to be used.
c. Final inspection by Board of Health staff or consultant
d. Installation of m*D-Box,pipes, stone, vent,pump cbamber, retaining wall and other
components.
6. As the installer, I understand that I am solely responsible for the installation of the system as per the
approved oved121ans No instructions by the homeowner general contractor, or any other persons shall absolve
me of this obligation.
Undersigned Licensed Septic Installer: (Toda}.'s Date) c;,7-19 7-4
-(o �� 1-250/✓
acne— Print i a —�ignc
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AS, BUILT PLAN r -
i OF
SUBSURFACE DISPOSALYS ` :* F{
LOCATED IN �
AS PREPARED FOR
O-D. -M\LL COI1Sl.Y.T101S ::r ;�r
DATE: �ij)� ;
`f 3O, ` X377 ��ZN OF
SCALE: „yG
' ROBERT C.
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MERRIMACK ENGINEERING SERVICES, INC.
PROFESSIONAL ENGINEERS • .LAND SURVEYORS • PLANNERS
66 PARK STREET • ANOOVER, MASSACHUSETTS 01810 Or TEL (617) 473-3553..3m$721
. i
Commonwealth of Massachusetts �' r
City/Town of I APR 9 2007
System Pumping Record
Form 4 TOWN OF ESC?TN ANDOVER
HEALTH
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. System Location.
fomes the Y -e
computer,use
only the tab key Address ?:�
to move your /o/(4�A_
cursor-do not l
Cityrrown Zip Code
use the return /State
.key.
2. System Owner:
Name
Address(if different from..location)
CityfTown State
• _ ����f.�—�% Code'
Telephone Number
B. Pumping Record
1: Date.of Pumping � ✓���
Date 7QuantityPumped:
Gallons
3" Type of system: ❑ Cesspool(s) eptic Tank- El -tight Tank
❑ Other(describe)
4: Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? E] Yes ❑ No
5. Condition of.Sysfem;
6. System u PeoY'
l r
Name a `
Vehicle License Number
• Company ---
7. location ere contents wer sposed::
Siynat e H ier `� `r Q
Date
h,ftp://www.mass.g e' ater/. pprovals/t5folms htmAnspect
t5forrm.doc-06/03
System.Pumping Record-Page 1 of 1
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i TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: . C�
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
S� ccaX
I IJV
DATE OF PUMPING: QUANTITY PUMPED GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE YEMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
f 1
SYSTEM PUMPED BY: iDSP
COMMENTS:
CONTENTS TRANSFERRED TO: -� • /�
TOWN OF Ldb VfL
SYSTEM PUMPING RECORD
T0T+11iV C3FpRTH ANlQO`!ER/
LC)F�?D OF HEALTH
DATE: � �
1 ,1f
SYSTEM OWNER& ADDRESS SYSTEM LOCATION_
(example:left front of house)
Wl �
DATE OF PUMPING: -0"---tj QUANTITY PUMPED i d GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER(EXPLAIN)
SYSTEM PUMPED BY: Bateson Enterprises, Inc.
COMMENTS:
coNTENTs TRANsFERRED TO: G.L.S.D Lowell Waste
Y I
P
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Septic System Information
54 OLD CART WAY
Printed On: Wednesday,April 16, 2008
System ID: BHS-2002-1139
General System Information Latest Permit Information
Calcaluted Design Flow: Test Pits Septic Tank Disposal Trench
Design Flow: One Two Capacity: Number:
Design Flow Provided: Minutes per inch: Width: Width:
Total Flow: Depth: Length: Length:
Seasonal: No No Depth to Water: Diameter: Leaching:
Grinder: No No Soil Type: Depth:
Laundry: No No
Haulinq/Pumping Listing Quantity
Type System Noe Pumped Pumped By Transferred To Disposed At Date Pumped (gallons)
Routine Septic Tank Bateson Ent GLSD 03/30/2007 1500
Comments: normal level in tank
Inspections:
Inspected: Expires: Inspector: Status:
02/27/2008 Neil J. Bateson Conditionally Passes
Comments: Title 5
GeoTMS®2008 Des Lauriers Municipal Solutions, Inc. Page 1 of 1
3?O.MORT.,M L
3201
O
ti 9
Town of North Andover
HEALTH DEPARTMENT
,s3ACHU
CHECK#: /'r DATE: Q5?,/O 4
LOCATION:
H/O NAME:
CONTRACTOR NAME:
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
1
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
❑ Septic Disposal Works Installers(DWI) $
❑ Zitle
5 Inspector $
i
5 Report $
❑ Other:(Indicate) $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer;
f /
16
COMMONWEALTH OF MASSACHUSETTS
Z f EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
d DEPARTMENT OF ENVIRONMENTAL PROTECTION
Q
'M Sve
MAR 1. 0 2008
TOlN'Nl i,i 1
1!r,Air.DOVER
TITLE 5
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 54 Old Cart Way_
North Andover_
Owner's Name: Michael Henry_
Owner's Address: 54 Old Cart Way
—North Andover,MA 01845_
Date of Inspection:_2/27/2008_
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 15.340 of Title 5(310 CMR 15.000). The system:
Passes
X Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
ails
c
Inspector's Signature: Date: _2/27/2008_
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:
I
****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.
t
Page 2 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:_54 Old Cart Way_
_North Andover—
Owner:—Henry_
Date of Inspection:_2/27/2008_
Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D
A. System Passes:
I
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:
X 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.Outlet tee in
septic tank needs replaced&D-boa.
N 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:
N 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:
N 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 Old Cart Way-
—North Andover—
Owner: Henry_
Date of Inspection:_2/27/2008_
C. Further Evaluation is Required by the Board of Health:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system
is failing to protect public health,safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the
system is not functioning in a manner which will protect public health,safety and the environment:
Cesspool or privy is within 50 feet of a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the
system is functioning in a manner that protects the public health,safety and environment:
_ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply.
The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well".Method used to determine distance_
"This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other
failure criteria are triggered.A copy of the analysis must be attached to this form.
3. Other:
Page 4 of 11
OFFICIAL INSPECTION FORM NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION(continued)
Property Address: 54 Old Cart Way_
_North Andover—
Owner: Henry_
Date of Inspection:_2/27/2008_
D. System Failure Criteria applicable to all systems:
You must indicate"yes"or`no"to each of the following for all inspections:
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 q
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 u
m imore 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.
_ _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface
water supply.
_No_ Any portion of a cesspool or privy is within a Zone 1 of a public well.
_No_ Any portion of a cesspool or privy is within 50 feet of a private water supply well.
_ _No_ Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water
supply well with no acceptable water quality analysis. [This system passes if the well water analysis,
performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds
indicates that the well is free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria
are triggered.A copy of the analysis must be attached to this form.]
No (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described
in 310 CMR 15.303,therefore the system fails.The system owner should contact the Board of Health to
determine what will be necessary to correct the failure
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either"yes"or"no"to each of the following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
the system is within 400 feet of a surface drinking water supply
_ the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped
Zone 11 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 Old Cart Way_
_North Andover_
Owner: Henry_
Date of Inspection:_2/27/2008_
Check if the following have been done.You must indicate"yes"or"no"as to each of the following:
Yes No
Yes Pumping information was provided by the owner,occupant,or Board of Health
No Were any of the system components pumped out in the previous two weeks?
I
_Yes_ Has the system received normal flows in the previous two week period?
i
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?
Yes_ — Was the facility or dwelling inspected for signs of sewage back up?
Yes _ Was the site inspected for signs of break out?
_Yes_ _ Were all system components,excluding the SAS,located on site?
_Yes_ _ Were the septic tank manholes uncovered,opened,and the interior of the tank inspected for the
condition of the 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.
_Yes_ _ 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)]
I
I
Page 6 of 11
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 54 Old Cart Way
—
North Andover_
Owner: Henry_
Date of Inspection:_2/27/2008 _
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms(design):_4_ Number of bedrooms(actual):_4_
DESIGN flow based on 310 CMR 15.203_600_
Number of current residents:_2
Does residence have a garbage grinder(yes or no):_Yes_
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 reading: Yes_
Sump pump(yes or no):_No
Last date of occupancy:_Current
COMMERCIAL/ENTDUSTRIAL
Type of establishment:
Design flow(based on 310 CMR 15.203): gpd
Basis of design flow(seats/persons/sgft,etc.):
Grease trap present(yes or no):_
Industrial waste holding tank present(yes or no):
Non-sanitary waste discharged to the Title 5 system(yes or no):_
Water meter readings,if available:
Last date of occupancy/use:
OTHER(describe):
GENERAL INFORMATION
Pumping Records
Source of information:_Pumped March 2007,owner_
Was system pumped as part of the inspection(yes or no):_No
If yes,volume pumped:,gallons--How was quantity pumped determined?
Reason for pumping: _
TYPE OF SYSTEM
_X_Septic tank,distribution box, soil absorption system
_Single cesspool_Overflow cesspool
_Privy
Shared system(yes or no)(if yes,attach previous inspection records,if any)
_Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be
obtained from system owner)
Tight tank _Attach a copy of the DEP approval
Other(describe):
Approximate age of all components,date installed(if known)and source of information_21 Years old,7/30/1987,
as built plan_
Were sewage odors detected when arriving at the site(yes or no):_NO_
Page 7 of I 1
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Old Cart Way_
_North Andover_
Owner: Henry_
Date of Inspection:_2/27/2008_
BUILDING SEWER_X_ (locate on site plan)
Depth below grade:_18"_
Materials of construction: _X_cast iron _X_40 PVC_other
Distance from private water supply well or suction line:
Comments(on condition of joints,venting,evidence of leakage,etc.) _4"Cast iron thru wall,3"PVC in house,
no leaks visible
SEPTIC TANK:
Depth below grade:_6"
Material of construction: X concrete_metal_fiberglass polyethylene
other(explain)
If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of
certificate)
Dimensions: 10'x 5'x 4'
Sludge depth —211_
Distance from top of sludge to bottom of outlet tee or baffle: N/A_
Scum thickness:_311
_
Distance from top of scum to top of outlet tee or baffle:_N/A N/A Outlet tee badly corroded.
Distance from bottom of scum to bottom of outlet tee or baffle: N/A
How were dimensions determined:_
Comments(on pumping recommendations,inlet and outlet tee or baffle condition, structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc._Inlet tee ok.Outlet tee badly corroded,needs replaced.
Depth of liquid at invert.No evidence of leakage._
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(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels
as related to outlet invert,evidence of leakage,etc.):
Page 8 of 11
OFFICIAL INSPECTION FORM —NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION(continued)
Property Address: 54 Old Cart Way_
_North Andover_
Owner: Henry_
Date of Inspection:_2/27/2008
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
Depth below grade _6"_
Depth of liquid level above outlet invert:—0_
Comments(note if box is level and distribution to outlets equal,any evidence of solids carryover,any evidence of
leakage into or out of box,etc.) _D-box level&distribution equal.Evidence of leakage.Light carryover.D-
box cover broken replaced it.D-box badly corroded needs replaced._
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 Old Cart Way_
_North Andover—
Owner: Henry_
Date of Inspection:_2/27/2008_
SOIL ABSORPTION SYSTEM(SAS):_X (locate on site plan,excavation not required)
If SAS not located explain why:
Type
Leaching pits,number: _
Leaching chambers,number:—
Leaching galleries,number:
_Leaching trench,number,length:
_X Leaching field,number,dimensions: _1 field 20' x 55'_
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.):—Snow cover above field.No sign of ponding to surface. _
CESSPOOLS:
Number and configuration:—
Depth—top of liquid to inlet invert:
Depth of sludge layer:—
Depth of scum layer:—
Dimensions of cesspool:_
Materials of construction: _
Indication of groundwater inflow(yes or no):
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
PRIVY: (locate on site plan)
Materials of construction:
Dimensions:
Depth of solids:
Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.):
Page 10 of 11
OFFICIAL INSPECTION FORM -NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 54 Old Cart Way_
_North Andover–
Owner: Henry_
Date of Inspection: 2/27/2008_
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 here public water supply enters the building
I
—D-Box
Septic Tank
A to Inlet=32'5"
A to Outlet=36'
A to D-Box=44'
B to Inlet=3116"
B to Outlet=3816"
B to D-Box=46' B
House
Water Meter
Driveway
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 Old Cart Way_
_North Andover—
Owner: Henry_
Date of Inspection:_2/27/2008_
SITE EXAM
Slope_Slight_
Surface water No
Check cellar _Dry_
Shallow wells_No_
Estimated depth to ground water_4'_
Please indicate(check)all methods used to determine the high ground water elevation:
X Obtained from system design plans on record-If cbecked,date of design plan reviewed:_5/10/1984_
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:_4' below system as per test pit data on
design plan_
i
-.•. ••�•� -•..nv mu'd m =v Nd61ZUU5 5:*4:UJ AM Dy KAW Hanlon Page 1
v Town of North Andover
Tax Map # 210-107.B-0086-0000.0
54 OLD CART WAY
HENRY, MICHAEL G.
54 OLD CART WAY
N. ANDOVER, MA
_ 01845
Class 101 Single Family Property Type-------1 Residential
Size Total 1.12 Acres
FY 2008
UB Mailing Index
Name/Address Type Loan Number Active/Inact. From Until
HENRY,MICHAEL G. Payor
54 OLD CART WAY
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 13764.0-54 OLD CART WAY Last Billing Date 2/8/2008
1090441 01 Cycle 01 Active
I
UB Services Maint.
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 64.62 /1
UB Meter Maintenance
Serial No Status Location Brand Type Size YTD Cons
32772792 a Active ERT HH b Badger w Water 0.63 0.63
Date Reading Code Consumption Posted Date Variance
1/28/2008 242 a Actual 18 2/19/2008 -64%
10/24/2007 224 a Actual 50 11/16/2007 48%
7/20/2007 174 a Actual 32 8/15/2007 42%
4/20/2007 142 a Actual 20 5/21/2007 -5%
1/29/2007 122 a Actual 25 2/20/2007 -41%
10/25/2006 97 a Actual 39 11/16/2006 19%
7/28/2006 58 a Actual 32 8/18/2006 39%
5/2/2006 26 a Actual 26 5/16/2006 -100%
1/24/2006 0 n New Meter 0 2/13/2006 -100%
1/24/2006 2748 r Replacement 25 2/13/2006 -45%
10/27/2005 2723 a Actual 48 11/9/2005 24%
7/25/2005 2675 a Actual 39 8/10/2005 41%
4/21/2005 2636 a Actual 23 5/13/2005 -3%
2/1/2005 2613 a Actual 29 2/15/2005 -23%
10/27/2004 2584 a Actual 33 11/15/2004 -28%
8/3/2004 2551 a Actual 46 8/25/2004 92%
5/10/2004 2505 m Manual estimate 27 6/8/2004 -31%
2/4/2004 2478 a Actual 38 2/24/2004 0%
11/3/2003 2440 n New Meter 0 11/3/2003 0%
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating-Water& Sewer Lines-Septic Systems&Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 54 Old Cart Way, North Andover
Owner: Henry
Date of Inspection: 2/27/2008
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
qBeson Ne
Bateson Enterprises, Inc.
Commonwealth of Massachusetts RECEIVED
City/Town of
a
W° System Pumping Record DEC 15 2009
,M Form 4
TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Boards of Health. Oth HETH TrvtFN
ALDEARhe
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: eft side of hour fight side of house, Left front of house, Right front of house,
Left rear of house, Ri t rear of house. Le rear of building. Right rear of building.
A o C--c-11-k- `z�-
Address '�j ac)
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town State Zip Code
)z -
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped: l SDC)
Date Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes /No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
0(M6�-l ItA It (c
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Locatiopwhq a contents were disposed:
G.L.S.D Lowell Waste Water
Signature 6f Hauler Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
4448
Of NO eTM 9h
Town of North Andover
HEALTH DEPARTMENT
S�cNuse
CHECK#: D T
LOCATION:
H/O NAME:
CONTRACTOR NAME:
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) $
❑ �Titlespector $
Title 5 Report $ �o•
O (Indica $
Health Agent Initials
White-Applicant Yellow-Health Pink-Treasurer
���rr•� ;;a � :a� . «asc"'?r:,3s;Fa�'4RF,,K,�u�. � A .;�.�m� .�� ,v .�,�,;,M
Of,MO RT: �.
~ ♦� 2 .i
Town of North Andover
`�ssACMUS��' HEALTH DEPARTMENT
CHECK#: Q� DAT
I
LOCATION:
f �
� H/O NAME:
CONTRACTOR NAME:
` Type of Permit or License:(Check box)
❑ Animal $
❑ Body Art Establishment $
I
❑ Body Art Practitioner $ j
❑ Dumpster $
❑ Food Service-Type. $
❑ -Funeral Directors $
{ ❑ Massage Establishment $
❑ Massage Practice $
f ❑ Offal(Septic)Hauler $
M a
❑ Recreational Camp $
;j
❑ Sun tanning $
❑ Swimming Pool $
❑ Tobacco $
❑ TrashlSolid Waste Hauler $
❑ Well Construction $
SEPTIC S,sy tems:
❑ Septic-Soil Testing $
❑ Septic-Design Approval $
❑ Septic Disposal Works Construction(DWC) $
i
❑ Septic Disposal Works Installers(DWI) $
❑ Title Inspector $
Title 5 Report $ '�•
a
O (Indicat $
1
Health Agent Initials
White Applicant Yellow-Health Pink-Treasurer
CoMmon`wealth of Massachusefts ` RECEIVED
ti - - Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessme is FEB ' 2010
� 54 Old Cart Way ' TOWN OF NORTH ANDOVER
Property Address }
Laurie Ferguson
Owner Owner's Name
!information is North Andover MA 01845 1/20/2010
required for
for '
every page. City/Town State Zip Code Date of Inspection
v�
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: A. General Information
When filling out
forms on the
computer,use 1. Inspector
only the tab key
to move your Neil J. Bateson
cursor-do not Name of Inspector
use the return
key. Bateson Enterprises Inc.
K. Company Name
+ " r� 111 Argilla Road
Company Address
Andover Ma 01810
city/town State Zip Code
978-475-4786 _ SI15
Telephone Number License Number
B. Certification
I certify that I have personalty 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 El Conditionally Passes ❑! Fails
❑ Ne s Further Evaluation by the Local Approving Authority
ff/j J- A, P
1./20/2010
In ,pecto s Sign.. Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a sham 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.
t51ns•09M Me 5 official Impeatian Fo... subsurface sewage Disposal system-Page 1 or 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. City/Town. 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 extiltration 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 structuraily soured, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND(Explain below):
t5ins-09/08
Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
c�M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for 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:
I
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes"or"No"to each of the following for all inspections:
Yes No
E] ® 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•09108 Title 5 Oficial Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
. Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Fong-Not for Voluntary Assessments
Jy54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
requited for North Andover MA 01845 1/20./2010
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier,if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soilabsorption 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.
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
El ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
El ® Static liquid level in the distribution box above outlet invert due to an overloaded
s
or cf099 or ce s
ed SAS Pooli
❑ 0 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
54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. Cityfrown 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
❑ ❑ Y (
Area—IWPA)or a mapped Zone 11 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 Title 5 Official Inspection Form: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
M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is North Andover MA 01845 1/20/2010
required for
every page. Citylrown 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?
® El available
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
® El
information on thero er maintenance of subsurface sewage disposal systems?
P p 9 P Y
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•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
w Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form- Not for Voluntary Assessments
�M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
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): Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
I
General Information
Pumping Records:
Pumped Dec 2009
Source of information:
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 ator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•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
M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
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:
D-box&outlet tee in septic tank was replaced 2008, Tank&Leach Bed installed 7/30/1987, as built
plan & info at B.O.H.
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 1.5
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
I
Septic Tank(locate on site plan):
Depth below grade: .5
feet
Material of construction:
® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 10' x 5'x 4'
Sludge depth: 0
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
27"
Scum thickness 0
Distance from top of scum to top of outlet tee or baffle
8"
Distance from bottom of scum to bottom of outlet tee or baffle
21"
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.):
Inlet tee partially clogged , cleaned same now ok. Outlet tee ok. Depth of liquid at outlet invert. No
evidence of leakage.
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•09108 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
M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity:
gallons
Design Flow: gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•09/08 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
54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
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 0
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
D-Box level &distibution equal, has flow levelers. No evidence of leakage. No evidence of carryover.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. CityrTown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
❑ leaching chambers number:
❑ leaching galleries number:
❑ leaching trenches number, length:
® leaching fields number, dimensions:
1 field 20'x 55'
❑ 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 snow covered. No sign of ponding to surface.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
I
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 Oficial Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
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
54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. Citylrown State Zip Code Date of Inspedion
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
i
a- 3
Dc",vZ-
UJt3
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
M 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
® Check cellar
® Shallow wells
Estimated depth to high ground water: 4
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 5/10/1984
Date
❑ 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 how9
ou established the high round water elevation:
Y 9
4' below leach bed 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 ficial 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
wM 54 Old Cart Way
Property Address
Laurie Ferguson
Owner Owner's Name
information is
required for North Andover MA 01845 1/20/2010
every page. Citylrown 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•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Summary Record Card generated on 1/21/201011:05:04 AM by Lisa Evans Page 1
Town of North Andover
Tax Map # 210-107.B-0086-0000.0
Parcel Id 18199
54 OLD CART WAY
LYNN FERGUSON
54 OLD CART WAY
NORTH ANDOVER, MA 01845
Class 101 Single Family Property Type 1 Residential
Size Total 1.12 Acres
FY 2010
UB Maifina Index
Name/Address Type Loan Number Active/lnact. From Until
LYNN FERGUSON Owner
54 OLD CART WAY
NORTH ANDOVER,MA 01845
HENRY,MICHAEL G. Previous Customer Inactive 2/12/2009
54 OLD CART WAY
N.ANDOVER,MA
01845
UB Account Maint.
Account No Cycle Occupant Name Active/Inactive
Bldg Id. 13764.0-54 OLD CART WAY 'Last Billing Date 11/3/2009
1090441 01 Cycle 01 Active
UB Services Maint.
Account No. 1090441
Service Code Rate Charge Multiplier/Users
MISCFEE ADMIN FEE 0.635/8 7.82 1/
WTR WATER 01 ALL METER SIZE 68.40 /1
UB Meter Maintenance
Account No. 1090441
Serial No Status Location Brand Type Size YTD Cons
32772792 a Active 00 b Badger w Water 0.63 0.63 194
Date Reading Code Consumption Posted Date Variance
10/22/2009 452 a Actual 18 11/11/2009 -47%
7/24/2009 434 aActual 21 8/12/2009 1%
5/29/2009 413 f Final Bill 13 6/1/2009 141%
4/24/2009 400 a Actual 14 5/13/2009 -5%
1/23/2009 386 a Actual 15 2/10/2009 -75%
10/22/2008 371 a Actual 59 11112/2008 7%
7/22/2008 312 a Actual 54 8/15/2008 223%
4/23/2008 258 a Actual 16 5/19/2008 -1%
1/28/2008 242 a Actual 18 2/19/2008 -64%
1.0/24/2007 224 a Actual 50 11/16/2007 48%
7/20/2007 174 a Actual 32 8/15/2007 42%
4/20/2007 142 a Actual 20 5/21/2007 -5%
1/29/2007 122 a Actual 25 2/20/2007 -41%
10/25/2006 97 a Actual 39 11/16/2006 19%
7/28/2006 58 a Actual 32 8/18/2006 39%
5/2/2006 26 a Actual 26 5/16/2006 -100%
1/24/2006 0 n New Meter 0 2/13/2006 -100%
1/24/2006 2748 r Replacement 25 2/13/2006 -45%
10/27/2005 2723 a Actual 48 11/9/2005 24%
7/25/2005 2675 a Actual 39 8/10/2005 41%
4/21/2005 2636 a Actual 23 5/13/2005 -3%
2/1/2005 2613 a Actual 29 2/15/2005 -23%
10/27/2004 2584 a Actual 33 11/15/2004 -28%
8/3/2004 2551 a Actual 46 8/25/2004 92%
Commonwealth of Massachusetts
City/Town of
a System Pumping Record D►
Form 4 RECIV
M
DEP has provided this form for use by local Boards of Health. Other form may16eYuf?e5, 40t6e
information must be substantially the same as that provided here. Beforesin this form, check wit your
local Board of Health to determine the form they use. The System Pumpi K4SAW810MIKIi ed to
the local Board of Health or other approving authority. LTH DEPARTMENT
A. Facility Information
1. System Location: Left front of house, right front of ho efts , right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner:
Name
Address(if different from location)
City/Town -7 / Zi o
� 3
Telephone Number
B. Pumping Record
p 9
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) CrSeptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes 9-9-0 If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of ystem:
6. System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Lo where contents were disposed:
G.L.S. w Waste ate
Signature df F14ulertDate
t5form4.doc•06/03 System Pumping Record•Page 1 of 1