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Miscellaneous - 55 STONECLEAVE ROAD 4/30/2018 (2)
f'" .z �'� � I .'; � � �� "1 � i :,i � 1 II;� � � C3 a f'^ !, ;�i � I ,� I �i �� :�� ' "",S q a i . _ . II i • PUBLIC HEALTH DEPARTMENT Town of North Andover Community and Economic Development Division CERTIFICATE OF. COMPLIANCE As of: 11/7/16 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Repair of Tank & D-box By: Todd Bateson At: 55 Stonedeave Road Map 104.B Lot 0143 North Andover, MA 01845 ,The isance-of this certificate alt be construed as a guarantee that the system will function satisfactorily. L Mkchele Grant Public Health Agent 120 Main St.,North Andover,Massachusetts 01845 Phone 918.688.9540 fax 918.688.9542 Web www.northandoverma.gov • 4 North Andover Health Department (ommunity and Economic Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 55 Stonecleave Rd. MAP: 104.13 LOT: 0143 INSTALLER: Todd Bateson DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS Septic Tank & D-Box INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS F/ Contractor reports any changes to design plan Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan D-' Bottom of tank hole has 6" stone base ❑ Weep hole plugged [✓� 1500 gallon tank has been installed / H-10 loading [�( Monolithic tank construction Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under accessp ort as baffle/effluent filter) ) ❑ inch cover to within 6" of finish grade installed over one access port Hydraulic cement around inlet & outlet Comments: ` & 0"4v"Lk— PUMP CHA &,L ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX Ei" Installed on stable stone base H-20 D-Box R/j Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets bserved even distribution Speed levelers provided (not required) Schedule 40 PVC Pipe Comments: Commonwealth of Massachusetts Map-Block-Lot 104.60143 • BOARD OF HEALTH ----------------------- Permit No North Andover BHP-2016-0456 ----------------------- FEE $175.00 ---- ------------------ DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted Todd Bateson ------------ to(Repair)an Individual Sewage Disposal System. at No 55 STONECLEAVE ROAD ---------------------------------- ------------- as shown on the application for Disposal Works Construction Permit No. BHP-2016-0 D to Oct ber 27,2016 ----- ---- ---- Issued On:Oct-27-2016 ------------------ ------------------------------------------------------------ BOARD OF HE TH Application for Sic Disposal System L - �- /4- Septic TODAY'S DATE Construction Pennit - TOWN OF $250.00'—Full Repair NORTH ANDOVER, MA 01845 -Component Application is hereby made for a permit to: ❑Construct a new on-site sewage disposal system* ❑Repair or replace an existing.on-site sewage disposal'system* Despair or replace an existing system component-What? �2n�r L /�.✓�l �— vtC A. Facility Information Address or Lot# wmmmn ,A///r rn1 . OCT LU lel Cityrrown 2:*TYPE OF SBEPW SYSTEM*: TOWN OF NORTH ANDOVER ➢ ❑Pump Gravity(choose one) HKTH DEPARTMENT * 11`pump sy m,aftach copy of electrical permit to application*"* ➢ 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) ➢ ❑Pressure Dosed(D-Box Present)S.A.S. / ➢ ❑ Does the system require an effluent filter? Yes No ✓ If yes, does plan specify make and model of filter? YES=(no further info.needed) NO=(installer must specify brand of filter before DWC issuance) What is the Make? WAatis the modes 2. Owner Information Name S7���QG("t/jL ?. Address(if different from above) _ ev Cityrrown State Zip Code `)8' 4-a — 77 43 Telephone Number 3. Installer Information Name Name of Company 6ATEOON ENTERPRISES,INC. Address 111 ARG 1 LLA ROAD A9 L ANDOVER,MA 01810 Cityrrown. State Zip Code qj `I8' ?A -ct7o_3 Telephone Number(Cell Phone#if possible please) 4. Designer Information 9 Name Name of Company Address City/Town I State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 WykApplipatioh for Septic Disposal system TODAY'S DATE p Construction Permit ' TONT OF ORTH ANDOVER. MA 01.845 $.250.06 T Full Repair 5 S $125.00.-Component s�cra ' PAGE 2 OF 2 A. Facility.Informatio.n continued.... 5. Type,of Building: Enesidential Dwelling or[]Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage dlsposal system In accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of North Andover,and not to place the system In operation until a Certificate of Compliance has been Issued is Board of Heath. Name Date %Ap{ li qtlo Approve -B, oa PP / ( rd of ea representative) �N e _ v Date Application Disapproved.for the following reasons: For Office Use Only 1. Pee Attached? . Yeo No 2.. Projectlt 2629'et Obligation Form Attachcd? Yes No ' .. 3.: ac'stem? Ifso)Attach conn ofElectrical Permit Yes_ No 4. Foundation As Built,?(hew construction-ronly): Yes (Same scale as approved plan) No S. FloorPlans?Mew construction only): No ApplCcatlon{or.p(spp$al Systerit: Page 2 of on*uction Permft, • s rVIMF t►+t di r o, r� !► lB ':OBLiGATJQ 1�5 An f$e-Npt&Aadaverlicmed hump:t f0.r pt*•stat wft-'A septic q8ta ft-i {Ad r eftgatc+ytoaa} Acltpun by Re3ativa m ttt�.applteado�t off`" ®�Qe�. ¢..esvo✓' ph r� Aad dated Dated o : a Vomit MVid tt dated -77 • {Lau 'sed d.te} I nadetic foDowIng►ikblfgations fot. cut of b prones 1. Al thefost ue4 I sm.oblrgated to abWSPIIpeaAift aadBoatd oflriadth q, 3F and PLInuft ti'D �of rvkoNW4aap: as aitm. Imaethat thA ;fin • .... .: - 2. At�@u fIte�.I.tauat caA jot any and it$' I�h� pectmatmgGt,or anp ��,�� iaapecdaa andfiam" Ibc syatcta is aotnady,t •� �; 4_baviee9dpticta the As- 6 al •btr dan '' lot a Ohm loutea•aot bave to be prtsaut •• a �+ab�OTS"(ot atnell•tix fi�m the edgmp&mtw. -bo t6idided•to lho-Bow-cfHeatk of t; as tieoe.'I 1te=must - • '. .Pt��., •. tbat F���' #�at:tie Ldp affable ca" ��- t Iter sa tregaeat`iasgeeaoaa►hep rlt ,eax ii e; Ius�}iei does szot 4. Asihe fQat dIM-I ung t that oily I~m9 F ! '{ 'r t a )and �i tEggired apiete that of tine syat�egi Id frt#tit;� ppi ioi&iioa j• i oaf r Aid•• Ak 6ai im •t,Y ttitdttatattd A; DO Q f. l t &s of rj r _ coswdmd. to awd JWAWP=dwbjrBbwQ�� �AltbdlA tll d l4fm&fibAdf&wkD- mg p ►,stoate,vaaat,PMP &",iftawvm►;xwother •�rlijp;w�lwTr�•�w:�y�� � � ' - y�dt��.tl:�a-nanRO�pf@ .. -�SG�,,,,.a�R Ab�ei�inn_ .. '• - +r+Y.c�..lr••,...�y.a,,vs� , Uaderaid�Sgsdc.I� '' : (Foft4 ss�s D' . North Andover Health Department (ommunity and Economic Development Division Septic System Pumping Records Date: 8/23/16 Address: 55 Stonecleave Road Condition of system: Tank leaking Dear Homeowner: Please note that a septic system pumping record dated 8/9/16 and received on 8/15/16 states that your tank is leaking. This indicates that repairs may need to be performed on your current septic system. Please have your system inspected by a licensed Title 5 inspector as soon as possible. Attached is a list of Title 5 septic inspectors that are permitted through the North Andover Health Department. If you have any questions or concerns,please contact the Health Department at the phone number listed below. Thank you for taking the time to consider the impact this may have on your system as well as the environment. Si e y, Ban aGrasse Director of Public Health Enc: Title 5 inspectors List Ulm" 1 g6W ani--, � OZ Page 1 of 1 North Andover Health Department, 1600 Osgood Street, Suite 2035 North Andover, MA 01845 Phone: 978.688.9540 Fax: 978.688.8476 /I Commonwealth of MassachusettstECE1VED Cityffown of AUG 15 2016 Si tem Pumping-Record TOWN OF NORTH ANDOVER s•• Form 4 HEALTH DEPARTMENT DEP has provided this form for use--by local Boards of Health. Other forms may be*used,but the information-must be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the form they use.The System Pumping in Record must be submitted ed to . the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left iah#fren#of liouse.Left/Right rear of house, Left/right side of house, Left 1 Right side of building, Left/Right front of building, Left/Right rear of building, Under deck . Address City/Town State - Zip Code 2. System Owner. Name' Address(if different from location) City/Town •. State ^ p Code ; f Telephone Number .B. Pumping Record 1. Date of Pumping 2. Quanti Pumped: P g Date Gallon 3. Type-of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes a4o If yes, was it cleaned? ❑ Yes ❑ No, ' S. Condition of System: 6. System Pumped By: Neil.Bateson ' F5821 Name Vehicle License Number Bateson Enterprises Inc- Company 7. Location ere contents-were disposed: GLS'. Lowell Waste Water Sin a Haul 9 Date t5formCdoc•06/03 System Pumping Record•Page 1 of 1 Tow19lF ��� 7°W ,r '.� 90A-RD dF . 9 4' JUL; 9 199 1 Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F.Weld Trudy Coxe Argeo Paul Celluccl Secretary U.Governor David B.Struhs Commissioner SUBSURFACE SEWAGE DISPO9AI.SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address;- `J 5 �S"e..ctecwe —L U04b., of Owner. Date of Inspection: (3--� (If different) Name of Inspector.%461 T&k�`jr) Company Name,Address and Telephone Number. BATESON ENTERPRISES, INC. TEL(508)475-1474 Excavating-Water&Sewer lines-Septic Systems&Pumping Service FAX:(508)475-5451 111 Argilla Road . Andover,Mass.01810 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: Zasses �. Conditionally.Passes t,, - - Needs.Further Evaluation By:the.Local Approving Authority --Fails. A r Y Inspector's Signature: Date: IS—C417 The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a des' flow of 10,000 or ter,the inspector and the tgt► gpd gree pact 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,13, C,or D: A) 3Y PASSES: • 77I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system,upon completion of the replacement or repair,passes inspection. Indicate yes,no,or not determined(Y, N,or ND). Describe basis of determination in all instances. If"not determined",explain why not) The septic tank is metal, cracked,structurally.unsound,shows substantial infiltration or exfiltration,.or tank failure is imminent..-The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. • s. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02106 0 FAX(617)556-1049 a Telephone(617)292-5500 i��t Pnnted on Recycled Paper P V SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: Y1�1� R"— Owner Date of Inspection: rn 4 B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken,settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed 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 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 NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMEN`14 Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feat of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT 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 mnwtom Iwo s aretatia tie and sail+*Pep ion oystkm"d is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile 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 leas than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 5� �t ' ' t Owner. f iVA 't� Date of Inspection: D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or-cesspool. 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 boa 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 dogged 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""pool or privy is within 100 foot of a surfaer wator supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. , Any portion of a cesspool or-privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. 'If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. El LARGE SYSTEM FAILS: The followingcriteria 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.. • 4 (revised 11/03/95) 3 ti SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address (Son e_,!:Aea / Owner. �' ` Date of Inspeetion: Check if the folio have been done: 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 flow rates d that.period. Large solum of water have not bee introdu into the system ntly or as of this inspection. poa AAA IC _As t plans have been obtained and examined. Note ifthe�r,are not avaL%*e with R/A. ty or dwelling was inspected for signs of sewage back-up. system does not receive non-sanitary or industrial waste flow _The as inspected for signs of breakout. M components,excluding the Soli Absorption System, have Ern las#W on tb@ sit®, _The se is tank manholes were uncovered, opened, and the interior of the septic task was inspected for condition of baffles or material of construction,dimensions, depth of liquid,depth of sludge,depth of scum. _The 'e and location of the Soil Absorption System on the site has been determined based on existing information or a rcximated by non-intrusive methods. _The facility owner_(and occupants, if different from owner)were provided with information on the proper maintenance of Sub- Surface Disposal System. (revised 11/03/95) 4 Y + SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Prop"Address: J�Jr �� G�� 004�\ ' Date of Iaspection:� 1 FLOW CONDITIONS RESIDENTIAL- Design ESIDENTIAL-Design flow:�)Q nllons Number of bedrooms: LA Number 'of current residents: a Garbage grinder(yes or no):_TO7 Laundry connected to systgpnO(,yes or no): 1 Seasonal use(;yes n no Water meter readings,ift available:—ailable: Last date of occupancy: Gy COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow:__gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter read np, if available: Last date of occupancy: OTHER(Describe) . Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: p ri ©WAS System pumped as part of inspection: (yes or no)AP �t If yes,volume pumped; - setllnns Reason for pumping: TYPE 9F'SYSTEM t/ 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) Other(explain) PR XIMATE AGE ofAll com nents/date installed(if known)and source of information: �AeAvcrQ_ 6 � '` t.%jAVVY' Sewage odors detected when arriving at the site: (yes or no) � (revised 11/03/95) g SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address; 5S Owner. Date of Inspection: 1 V` w 1 Q VV-' (q, e� . Cr�3 g7 SEPTIC TANK: �( (locateon site plan) 11 A Depth below grade: Material of construction: loll _metal_FRP—other(explain) Dimensions: j=- f DO© _ ✓15 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:v� Scum thickness: fes— It Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: ttJ Comments: (recommendation for pumping, condit'on of inlet and outlet tees or hofTdep h of liquid level in lat' n to outl. in rt, grity e�}'dente of 1 etc.) �k- . © C>Jc'rw OY\ - 1t 1 1 ` N+� mai c� . e,�.�c� c WN ®r 2 (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP—other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping,condition of fillet and outlet tees or baffles,depth of liquid level in relatian to aotlot invert,strimu&W intepity; evidence of leakage,etc.) 4 (revised 11/03/95) 6 H ` SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMAT(ION� (continued,)) Property Address: �-5 s6y`ejcJ p—ew ...1�-�OCAA �. Owner. �\ • �H Q S Gx \ Date of Inspection: , b-13-Ct TIGHT OR HOLDING TANK.: y, (locate on site plan) Depth below grade: Material of construction:_concrete_metal_FRP_other(ezplam) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level_: Comments: (condition of inlet tee,condition of alarm and float switches, etc.) a, t DISTRIBUTION BOX- (locate OX(locate on site plan) Depth of liquid level above outlet invert: Comments: t' v (note if l 1 dist bu n is gal, evidence of solid-ca: er,e.' ence of leakage into or out of box, etc.) G� 2- V�( �. <9� f U PUMP CHAMBER:�CX�lc1cw` (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber,condition of pumps and appurtenances,etc.) III s (revised 11/03/95) 7 t SUBSURFACE SEWAPE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address Owner. �^ Date of Inspection: /—�' CU4 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible;excavation not required,but may be approximated by non-intrusive methods) If not determined to be present,explain: Type: leaching pits,number:_ leaching chambers,number:_ leaching galleries,number: (CJ cc�� ^O� / leaching trenches,number,leagth: cT �� [ leaching fields, number, dimensions: Cl overflow cesspool,number: � y Comments: (note con ' ion of so', signs of hydraulic l�ev 1 of ndin conditio egetat' etc.) \ U `" 'VN '� ft o Vol CESSPOOLS: (loaaW on site p*) 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: Mow(cmpool must be pumped as part of inspection) Comments: (note condition of soil,signs of hydraulic failure, level of ponding, condition of vegetation, etc. PRIVY:U\(7v\e,., (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments.(nots condition of sail, signs of by"utba f i_lum, Jowl of ponding,oaadition of vegetation,etc. (revised 11/03/95 S f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(oontinued) Property Ada:em Owner: l,C. W 1 V o� Q' Date of Inppeotion: 4V�c SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' Dno- 4Av 3 =3 a DEPTH TO GROUNDWATER Depth to groundwater:--�f _feet � Off` method of determination or approximation: ! 111 r a (revised 11/03/95) 9 IBATESON ENTLRPRISES INC, Septic Systems—Excavating—Water A 90*er Unti i i i Ai,gilla NaAd AfidcIvoti MiWA0661114 Titie 5 inspection ROpOtt. by Add rem a j Owner , W Ul0C/�/�'l Date Of InspeCtIont My reorb contained hokoffi dogg hot ebfigtitIAEO A uaranfoe of futdre U9946fit 6 gild the kuhttionalyit y f the oitlAting boptid by9ti 8Udh froom iddUed herewith 16 Merdiy babbld o0ofimy bbbotvaUbfig# and I hereby digbialfti AfiY fUtbhdf 6PbkAUbft tit yottk cdtteht septic 8yotbmt P.O. Box 489 . UIl si lnru�aurdtY'1 rJtlpn+n++v�MiuVU+_r+'+I 1"+Il + ��s'p�y YuuN';� � North Andover, MA � 0.845 i08-68.5-4200 FAX' 508.682.2180 FACSIMILE COVER SHEET s A r TO: DEPT: 13 Z— FROM: J�_S,¢,-✓do BLit/ # OF PAGES QNCLUC.NG COVER 9HE;6*0 COMMENTS: ee- 7 �_1C-°tJ �� « • '�` cw Y Q vesTid rS �� .Vis++ifl{Lv\+•T�'Rmtl'�•11�s^4M%` �{� r S� hw:r.rt+Sl�mln-%mmcar;:-+rc`1vrkd /_4 _. 1 Sni11 Worksheet Date: Signature: _ Stem I. No. c' gals . s:.illed step 2 . Tank Mix Fill Chart Code. �_ [� step 3 . Tank Mix Consisted of da-c'e5 ,�►�X _ —____. _. _ e�_ - ' — — Co VAO-✓ ,C;A F/_ step 4 . Tank Mix Solut;on weighs $' lbs/gal . (b) Ste 5 . (a; ,�, (ga=s sm; lled) X (b) 8: P total lbs , spilled Step 6 . Tan?, Mix Tank Mix ccmponents x (c) Tot. lbs . spilled = Ccmucnent. spilled NOTE: when mug_:plying by a cercent -move deci„aal 2 places to left , ?x. 2 . 92 _ . 0292 ) or use calculator with funct� , Step 7 . certilizer: 1 s of Nit-rogen, PIhcsphcr0U5 & Potassium spilled. ; �x /3Z—(c) total 1.ts sp .11e�' _ , 6L3Z Y =bs �r sn� l' ed 7 _ * s o sp .p o :< /3v (G) = 1b %1K .0d/ X—Zle,,(c) _ . 8//d -lbs K step a . Fes t:cides l:.s . of active ingredient (ai) spilled of pesticide sp;lled x (c) totj Ibs s ai pesticide spilled D26 of TA14m x total lbs ai 3. Y o. 06 of T,fx total lbs 139 -1b ai o, d2 oz q x total lbs l2 =1b ai w �( 02 of x total lbs -lb ai s of x total lbs =1b ai of x total lbs =1b ai I of x total. lbs =1b ai Dj4T�: ( l) Individual :esticides need to be calculated when pesticide ccm;, inations are spilled, (Ex: SWC-3 wh; cn conta;ns MC2A + MCPP + dicar,ba) (2) Taric mix weight, I N, P, K. and - pesticide found on back, of II Chary , (3 ) Transfer * n gibers to spill. Report and attach work- sheet to resort. TRUGREEN*CHEMLAWN LAWN CARE TANK MIX. CONTENT LABEL FI LLFI LE 13 551500 39 BRANCH PROGRAM NAME . 75/N PRE-M CONFRONT BANVELLOCAT£ON a FILL CODE LIEN NEW ENGLAND T ROUND 1TELEPHONE (508)747-0880 SPRAY VOLUME 2.00 GAL/1000 *Y:�=i:�F:Y: }=:l:a:�,k�%f=��:�;=1:���i:*�Nc xr k:�'.f':k:k'i: l:�:'F'�=�=�:K�::i;��►c k Y:-k:+c���l::K:k THIS TANK MIX WAS PREPARED FROM THE FOLLOWING LIST OF PRODUCTS: Product Name : 13-3- 25-6-5 :PRE-M 3. 3EC :CONFRONT Reg _ : BANVEL A Re it : 241-360-1.0404 : 62719-92 : 55947-1 _ RATE-APPLIED-__0750-I.,BAI/M`2 .000-I. PAI/A- : 0- 42,1 L13AT/A : 0 . 14�? 11BAI/A THIS TANK MIX CONTAINS THE FOLLOWING ACTIVE INGREDIENTS - - _ - - ------_------__--_-____ CHEMICAL NAME:NITROGEN :PENDIMETHALIN :TRICLOPYR : DICAMBA CONCENTRATION: 4. 2690 : 0. 26% 0 .06% 0 . 02% - -HEMICAL NAME:P205 CONCENTRATION: 1 . 06% - :CT -02% I,LD .'HEMICAL NAME: K2O _ 'ONGENTRATI ON: 2-13% .13% = ---___---------- _'HIS-MIXTURE-WEIGHS ===8. 80=POUNDS PER GALLON ------------------------------ -_-__--__-__-___ 10TICE TO FIRST RESPONDERS IN THE EVENT OF A- RELEASE: rEVEL D PERSONAL PROTECTIVE EQUIPMEN,r IS ADEQUATE TO AVOID EXPOSURE'0 RELEASES FROM THIS TANK, EXCEPT FOR RELEASES IN CONFINED SPACES-"OR ADDITIONAL INFORMATION CONCERNING THE COtJTCNTS OF THIS TANK 17XTURE CALL THE TELEPHONE NUMBER LISTED ABOVE_ IF AFTER CLOSE OF ;USINESS HOURS OR IN AN EMERGENCY CALL (800) 424-9300_ fYIA. •`*'� r ;. '�:*�****�********��fC*�':1::� `,. r..#'•4S:*�*���'�::}..� ; '.f'*IXC�C*�I:DC7{;**�c�k:xCk:�};***��'X'.1.�.**����*:a;:4. �::i:.=K%k�J4:�fCNC**�::4C:K�: .AtEEN*(:E+.L;MLAWN LAWN CARE FILLCIIAi.;T SYSTEM FILLFILE 1355150039 26-Mar-97 REGION NEW ENGLAND EMERGENCY CONTACT BRANCH st TELEPHONE4 BRANCH NEW ENGLAND ( 508 )747-0880 PROGRAM .75/N PRE-M CONFRONT BANVEL FILL CODE L1BN ROUND 1 VOLUME 2.00 GAL/1000 FILL SIZE 300.00 TOTAL GALLONS INCREMENT 25 .00 GALLONS/FILL LINA; PRODUCT 4 USE RATE SPEC FILL RATE FILL RATE -P*R ARE P m EC NAME **PER 1000 SPE EPAREG�#�:+ :x ILL 1 1009 '3 0.750 LBAI/M 2 ILL 2 10281 5 . 33 UAL 2 13-3- 25-6. 5 0. 58 GAL CLL 3 10286 - OOU LBAI/A 0- 60 GAL PRFs-M 3. 3EC 0. 01 GAL 241-360-1040 0. 424 LBAI/A 712- 47 MLS CONFRONT ILL 4 10235 0 . 149 LBAI/A lE_ 36 MLS 62719-92 'LL 5 142. 11 MLS BANVEL 3 -26 M£.S 5504"T-1 LL 6 y .{ (..y y.y l' y y y y y. J JJ,.y.y l'y .1r J .I ✓J' L f .y4 )MMEN)MMEN T•ITTT ?- TTT T 'T •T :� .T •-•[ TT .� •hof-,n T•TT-�T •F.T T'f•T T T iF T T T T T T TT.r�-f- TT• TS: WELL DATABASE AGE OF W�=L. 7, ELL D_ ' WELL LOC,,-- ON: �-J 0 ae ,-w- _t_n y 'DATy -JE2=OF W7—LL _-=OFT _L_ D =, o. DLit c_ TJ' a -O v Y EL=6y Y N CTC0NDA,ir AYiS. Y iv -- — _ _ a 4j ACF OF E L. -ti/L%� { �v r. L.L)Rti _LL PD T: ��WE'1.I. L O.�AT ON: C`,. � ICA �4LLL Pte: DA : DEP7I-- FALL: i YTE OF WELL: z. DFZLFD b. Dl1Ci c. L-`aK�, i0�r TYPE OF WA R BE-Aa2i G ROCK. WATER A�iA YSIS DAIS: HIGH,-Lr L-,-NL aA N-ESE: Y N HIGH LRON: Y N 07-EER CONTA-NIMNANTS: Y N J �r F/Bo,a..r, Of -. i t'TIC SYSTFX _ Nort}j A.ndoveriNabso -- INSTALLATICIN CMIZE LIST LOT i� /f' /c�ri�al JY G"JID DATE _ DISAPPr2UJED AVATICN ON FAIL . FAIL OK 1. Distance Tot a. Wetlands b. Drains c. We71 2. Water Line Location 3. No PVC Pipe �. Septic Tank a. Tess -_Length & To Clean-Out Comers. b. Cement Pipe to Tank - on Both Sides of Tank 5• Distribution Box a. Covers do Box - No Cracks b. All Lines Flowing Equal Aunts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Capped Ends i/ d. Clean Double Washed Stone r r 7. L ch Pits ' a. KA + b.c.d.e, to Pit - Both Sides f. Cly Double Washed Stpne 8. No Garbage DJt sposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location's - b. Dimensions of System ' = c. Location with Regard_to Pere Test F r d. Elevations t e: Water Table f I• 4 '*' -AV JZ pa W rr�T�r p � „ a 4Y,..1"9 � }t z u 3,.r �s l ¢ -:� �.c.•..-,s � .. ,a ` x ` w = �FORN SII- LO`L` RELEASE -FORM S all necessary ; R IICTIONS This "form mused to verify_ that. vals/permits::_.fron:_Boarda andrY Departments having--jurisdiction - been obtained.. This Udes �not''relieve the applicant and/or . landowner from compliance with any applicable local or state law,:;. ` ,. regulations or requirements. ****************Applicant fills out this section* * ************ APPLICANT: Phon t�5y _� t LOCATION: Assessor's Map Number Parcel Subdivision Lot(s) r� �iz���le�� _ ^ °-- Street J St. Number ************************Official Use Only************************ REC N TIONS OF TOWN AGENTS: Il ,1�; /1 l i VE. ,( � �— Date Approved C e tion Administrator Date Rejected Comments _ � �/✓�.� l U %�. lam' ► �L i;J t Date Approved Town Planner Date Rejected '. Comments it 8 i�rt`y iV+ Date A . PProved r,,-. -- Food spect -Health Date Rejected Date Approved 'tic Inspector-Health Date Rejected Comments 4 ^mss--� � � #- Public Works - sewer/water connections driveway permit Fire Department Received by Building Inspector Date NORTH ANDOVER BOARD OF HEALTH INSTALLATION C!MCK LIST APPR YED DATE DISAPPROVED DATE tXCAVATION OK REASONS: ?� q -3 -76 FAIL OK 1 . D' stance To: Wetlands- Drains etlandsDrains Well . Water Line Location ?. No PVC Pipe 4. ptic .Tank Tees - Length & To Clean Out Covers Cement Pipe to Tank - On Both Sides of Tank 5. stribution Box Cover & Box - No Cracks All Line-s Flowing Equal Amounts ZLea Flow or Trench ns pth nds uble Washed Stone 7. Leach Pits Dimensions Stone Depth Splash Pads Tees Cement Pipe to Pit - Both Sides Clean Double Washed Stone No Garbage Disposal Final Grading Inspection 1 Barracading Covered System 11 'lt Submitted Lot Location Dimensions of System Location with Regard to Pere Test Elevations Water Table TO: NORTH ANDOVER, MASS 197 BOARD OF HEALTH FROM: DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at �° T 7-0/VC Cz614 VNorth Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 OjS IVA101 W �d eg. i It *eg itarian Md3SOf 03 10 �i1 Ale- 77A."\ Jr-7/v NO PIPC 5 7- 7—IAI 1A O Lv Is, 0?-"gbA 4,19 W ;kg "'Po" NIIY3 NORTH ANDOVER BOARD OF HEALTH AP34ROVED.,DATE PROVIDED DISAPPROVED DATE TIME REASON q"tit Title 5 Reg. 2. 5 Fail OK The submitted plan must show as a minumum: tea:-) ~"the lot to be served (area,dimensions,lot #,abutters) .(Planning Board files) (b) location and log of deep observation holes-distance to ties (-cw),"" location and results of percolation tests-distance to ties (_d),design calculations & calculations showing required leaching area ...,00--location and dimensions of system (including reserve urea) existing and proposed contours (gig location of any wet areas within 100' of the sewage disposal system of disclaimer (check wetlands mapping) ` 7) surface and subsurface drains within 100' of sewage 1 disposal system or disclaimer � ( ) cation of any drainage easements within 100' of ! sewage disposal system or disclaimer (planning board files) j-)- known sources of water supply within 200' of sewage disposal system or disclaimer location of any proposed well to serve the lot (100' from leaching facility) location of water lines on property (10' from leaching facilities) - I (`m) location of benchmark I n driveways _,,(--o) garbage disposers p.)- no PVC is to be used in construction (q) a profile of the system (elevations of basement, plumbersi pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) CN"""D. . ___ _ (r) maximum ground water elevation in area of sewage disposal �system p h• ) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Septic Tanks Reg. 6 (a),.,-Capacities - 150% of flow, water table , tees , depth of tees , access, pumping, Cleanout (c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains a Fail OK Distribution Boxes Reg.10.2 ( Slope greater than 9.08 Reg.10.4 (b� Sump Leaching Pits Leaching pits are preferred where the installation is possible Reg.11 .2 (a Calculations of leaching area (minimum 500 S.F. ) Reg.11 .4 (b� Spacing - Reg.11 .1 (c) Surface drainage 2%. Reg.11 .11 (d) Cover material Leaching Fields Reg.15.1 (a) %Greater than 20 minutes/inch - Reg.15.1 (b) Area (minimum 900 S.F. ) Reg.15.4 (c) Construction of field Reg.15.8 (d) Surface drainage 2% Reg. 3.7 (e) 20' from- cellar wall or inground swimming pool Leaching Trenches Reg.14.1 Calculations of leaching area (min. 500 S.F.) Reg.14.3 --(-V) Spacing (4 ft. min. 6 ft. with reserve between) Reg.14.4 --Dimensions 14.5 Reg.14.6 {wd7)�Construction Reg.14.7 (e;)-- Stone Reg.14.1 _fes)""° Surface drainage 2% DownhillSlope R )' Slope y/x = (to be shown y/x X 150 = (to be shown PumpO Reg. 9.1 (a) Approval j Reg. 9.6 (b) Stand-by power Commonwealth of Massachusetts 115CF- ED City/Town of System Pumping Record �;� � � 2ot4 Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use,by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form,check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left i [t , Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address r` S5 V City/Town State Zip Code 2. System Owner. Name Address(if different from location) City/Town State ��}(� p de �� Telephone Number x r B. Pumping Record 1. Date of Pumping gate ;;ePtficTank Qua Pumped: Gallons 3. Type of system: E:] Cesspool(s) ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If.yes, was it cleaned? ❑ Yes ❑ No ' 5. Conditi g of.System: 6. System Pumped By. Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. LT e contents were disposed: S. Lowell Waste Water Sign Hau6iuDate t5f6mW.doc-06/03 System Pumping Record•Page 1 of 1 RECEIVED Commonwealth of Massachusetts City/Town of AUG 212012 System Pumping Record TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Form 4 M v DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left Ri ht front of hous Left/Right rear of house, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address City/Town State Zip Code 2. System Owner. Name Address(if different from location) Cityfrown State &<�rde Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) alSeptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Conditionoystem: C cam` 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Lowell Waste Water Signitufe qfHaule Date t5fonn4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record AUG 3 1 Z010 N S•moi Form 4 OF f�H {e ANDO DEP has provided this form for use by local Boards of Health. Other form P information must be substantially the same as that provided here. Before using this form, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health ofother approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of hous , ight=fiouse, Left rear of house, Right rear of house. Left rear of building. Right rear of bu Ing. 41 Address Cityrrown State Zip Code 2. System Owner: Name Address(if different from location) Citylrown State C Tel/ep/hone 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 If yes, was it cleaned? ❑ Yes ❑ No ' S. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location ere contents were disposed. L.S. Lowgfi W@ste Water Signatur Waur Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 l Commonwealth of Massachusetts SIVE City/Town of System Pumping Record SEP o 8 2008 Form 4 H ANDOVER DEP has provided this form for use by local Boards of Health.Other forms mk'be used,.butathW-LNT 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 Important: When filling out 1. System Location: forms on the computer,use only the tab key AddressG to move your 1 5 cursor-do not City/Town statfi Zip Code use the return keys 2. System Owner: qk= II vlName 11 Address(if different from location) City/Town State C Zip Code Telephone Number B. Pumping Record T L 1. Date of Pumping Date Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes leo If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of System: rw�Lc� 6. Syste u ped.By: Name V isle License Number Company 7. Location e e::ntts yveCe disposed: l , Sign e u er Date t5forrn4.doc^06/03 System Pumping Record•Page 1 of 1 L\ Commonwealth of Massachusetts City/Town of I RECEIVE® System Pumping Record Form 4 SEP - 6 2006 DEP has provided this form for use by local Boards of Health.. The S stem\Rurnp",9A.ow-r.m st be submitted to the local Board of Health or other approving authorit- . HEALTH DEPARTMENT A. Facility Information Important: When fining out 1. System Location: C fomes the computer,use only the tab key Address . to move your cursor-do not use theretum City/Town State Zip Code key. 2. System Owner: i Name nem Address(if different from location) CityfTown State /gip Telephone Number B. Pumping Record 1. Date.of PumpingDate 2. Quantity'Pumed: Gallons 3. Type of system: ❑ Cesspool(s) B-Isleptic Tank- ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes ❑rll o Ifes y , was It cleaned? El Yes ❑ No 6. Conditio of System: 6. System Pu ped+By: C) Name Vehicle License Number Company -- 7. Location w re contents disp Signature Ha er' 9tune Date http://www.mass.gov/dep/Water/approvals/t5forms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 EEIVED TOWN OF SYSTEM PUMP NG RECO19 2004 F NORTH DEPARTMENTANDOVER DATE: 021 � SYSTEM OWNER&ADDRESS SYSTEM LOCATION �ac �-f (example:left front of house) DATE OF PUMPING: ^ 6q QUANTITY PUMPED : 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 TOWN OF J� SYSTEM PUMPING RECORD DATE: �-Lq-oa- SYSTEM OWNER & ADDRESS SYSTEM LOCATION a<-C6 (example:left front of house) DATE OF PUMPING: _ ^D QUANTITY PUMPED : l�C3C� GALLO CESSPOOL: NO YES PTIC TANK: NO YES : NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE ROOTS LEACHF'IELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLIDS CARRYOVER OTHER(EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: ' wF TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: ,ZI_G I SYSTEM OWNER &ADDRESS SYSTEM LOCATION ff (example: left front of house) DATE OF PUMPING: QUANTITY PUMPED GALLONS YCESSPOOL: 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: COMMENTS: CONTENTS TRANSFERRED TO: Commonwealth of Massachusetts o ; Massachusetts W04 1 1 1997 System Pumping Record System Owner System Location Date of Pumping: . ( .— Quantity Pumped: ���� gallons Cesspool: No f Yes U Septic Tank: No "Yes System Pumped by: Vetad4rt giiL'eqw0a License# F Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: