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HomeMy WebLinkAboutMiscellaneous - 56 CRICKET LANE 4/30/2018 56 CRICKET LANE 210/107.A-0215-0000.0 J I 'f Commonwealth of Massachusetts Et 4 /Town of � tY _ 2013 C i System Pumping Record Form 4 _ . ;: `+� DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using-this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/Right front of house, Left ig �rear eft/right side of house, LeftRight side of building, Left/Right front of building lding, Under deck Address LA City/Town State Zip Code 2. System Owner. Name Address(if different from locatiopy citylrown State Zip Code Telephone Number B. Pumping Record n� 1. Date of PumpingDates (� 2- uantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No Ifes was it cleaned? Y ❑ Yes ❑ No. 5. Condition of System: Mal 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company . 7. Location where contents were disposed: G.L S. Lowell Waste Water Sign t e Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of I FAY System Pumping RecordForm 4 07 DEP has provided this form for use by local Boards of Health.:.The Sysiem Pumping Record must be submitted to the local Board of Health or other approving- tIa oil y. A. Facility Information Important: When filling out 1. System Location- formsonthe me� �1" computer, r,use f_cci/f only the tab key Address to move your cursor-do not C use the return ityff°wn State Zip Code key. 2. System Own Name Address(if different from location) Cityfrown State Zip Coder Telephone Number B. Pumping Record 1. Date.of PumpingQuantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight.Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes VNo Ifes was i y t cleaned? ❑ Yes ❑ No 5. Condition o ystem: 6. System Pumped By Name vehicle License Number Company -- - 7. Location where coptents were disposed-. Signature of Hauler Date ----------- http://wWw.mass.gov/dep/­Water/approvals/t5forms.htm#inspect t5form4.doc-06103 System Pimping Record•Page 1 of 1 Commonwealth of Massachusetts RM- se C'ty/Town of VED System Pumping-Record Form 4 Cf:M C U1 , HEAL DEP has provided this form for use-by local Boards of Health. Other formthe 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 hou Le Right ar of o , 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. s Name Address(if different from location) CW-town Zi_ ` statr Code ; Telephone Number B. Pumping Record 1. Date of Pumping co -31 Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) USepti Tank El Tight Tank ❑ Other describe : 4. Effluent Tee Filter present? ❑ Yes Leo If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of System: C -� V\- 4eA 6. System Pumped By: Neil.Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio re contents were disposed: Lowell Waste Water Sig Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 i TOWN OF �N - Ll SYSTEM PUMPING REC r --EINE® DATE: AUG 0 5 2005 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT SYSTEM OWNER& ADDRESS SYSTEM LOCATION (example:left front of house) ©�� S4 Cr 1,C�-e Lyn, DATE OF PUMPING: — 8' 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 Ira N Commonwealth.of Massachusetts City/Town of i System Pumping Record Form 4 MAY 0 3 2007 DEP has provided this form for use by local Boards of Health.. The System Pump ng7Record must be submitted to the local Board of Health or other approving authority.:. A. Facility Information Important: When filling out 1. Systerin Locatio forms the computer,use only the tab key Address to move your (57 (�/l� �'�T .�✓� cursor-do not use the return Gity/Town state Zip Code key. System Owner W i Name Address(if different from location) Cityfrown Stat Zip Code Telephone Number .B. Pumping. Record 1. .Date.of Pumping Date 2. Quantity`Pumped. Gallons I Type of system: ❑ Cesspool(s) 9-1SePtic Tank_ ❑ Ti ght:Tank: ❑ Other(descnbe). 4. Effluent Tee Filter present? ❑ Yes ❑'No If yes, was it cleaned? El Yes ❑ No 5. Condition of System- 6. Syste P meed By: i -�_ o a Name Vehicle License Number Company .7. Location ere codtents w isposed:: Signat a Ha ler Date h.Up://www.mass.gov/dep/­`waterla .provalt/t5fo rms.htm#inspect t5form4.doc•06103 System Pumping Record•Page 1 of 1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD .DATE ij�iFil 2 r F•+�i� 1}F SC6S „p;. i : 1 SYSTEM OWNER&ADDRESS SYSTEM LOCATION - (example: left front of house) � V � «�L'- � � s w t / D / 1 / i�✓U CJ �� DATE.OF PUMPING: 5���3-6) QUANTITY PUMPED ,Cx�GALLONS CES PO `NO YES TEM SEPTIC TANK: NO YES v + �!�'�H"i1�+�1Il�j�fkl� `4i1� k ta';• f � ", a NATURE OF SERVICE: ROUTINE. .y EMERGENCY '1 �;y ;:;p' , ; •, fir Q$SERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN PLACE _ ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED ' SOLIDS CARRYOVER_ OTHER(EXPLAIN) Frp Al SYSP". PED E Y: OMMENTS: : OF r+ '•t1 is i � ' ' �111r'r 4(t ref"" ��) h i CONTENTS TRANSFERRED TO: _� • c��c��c� i + � °i 'Ir•1 t ii.tP'u,„ ':K` 'I,u t + - � '� �`� 1 + Address .�.L G1rL�i�� �rY/ Title of File P. 1 ofi Date f=ile Open: ------- Date file Closed: Doc Docurnent/`Action Title Date of �� action Defer a other Purpose of Do Doc to /qct of nand notes; IWum. Document/ document/ -- Action De artrnent Board of Ap; ads — Board of Heal h Planning Board ; Conservation Commission — Building Department t ji 1 A 1 J, c ,1 t� �r A z; f i • I WV P12E OUT OF-N5_E buiL-r 11 J V PIPE I NToATAt�111� two/ APE QUTigrL NV_ ` •' .y a _ V�-5 U R.rp4c.F. D f 5 P05AL . tiNV-PIPE 1NT2 Dle>o Wizv!_ E�d o 0F PIPE '`,_: •� t rJ � I FG2ANIC CEt_1NAS ASSUGIAT'ES 1r' 4,-1- ye7 ENC-a1NEEt'2SRGF-tl'f��GT`3 4 St AcJ L�lER� �3T I�o..L�ri Oo'�I�-Q- j .� y Iii5 gTT �TTCI Lxsr Lor --� ^� DATE UI Ft�O"�L� llI T �XCAVA i`:ICJ OK FAI L Reasonst - OK 1. Distance Tot a. Wetlands L b. Drains c. Well / 2. Water Line Location i ' r 3• No PPC Pipe .. }�. Septic Tank--- a. ank-a. Tess -_Length Ec To Clean Ont Covers - / b. Cement Pipe to Tank - On Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing "Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions b. Stone Depth c. Coed Ends 3 d. Clean Double Washed Stone ?• Le/Pi , a. b. c. sd.e. e to Pit - Both Sides f. e Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection 14. Barricading Covered System ll. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard-to Pere Test d. Elevations e: Water Table Copy to Public Works A SUBSURFACE DISPOSAL SYSTEM CHECK LIST .0 tr NORTH ANDOVER BOARD OF HEALTH APPROVED DATE PROVIDED DISAPPROVED DATE TIME REASON Title 5 Reg. 2. 5 Fail OK The submitted plan must show as a minumum: (a) the lot to be served (area,dimensions ,lot #,abutters) (Planning Board files) OW ,-(-b) location and log of deep observation holes-distance to ties ,, ` -(c)' location and results of percolation tests-distance to ties 'd) design calculations & calculations showing required leaching area location and dimensions of system (including reserve area) existing and proposed contours (g location of any wet areas within 100' of the sewage disposal system of disclaimer (check wetlands mapping) - (h) surface and subsurface drains within 100' of sewage disposal system of disclaimer (i) location 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 k) location of any proposed well to serve the lot (100' from leaching facility) - (I) location of water lines on property (10' from leaching facilities.) (m) location of benchmark n) - driveways garbage disposers no PVC is to be used in construction ._ '(q) a profile of the system (elevations of basement, plumberE pipe septic tank, distribution box inlets and outlets , distribution field piping and any other elevations) (r) maximum ground water elevation in area of sewage disposal system (s) 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, (b) Cleanout (c) 10' from cellar wall or inground swimming pool (d) 25' from subsurface drains f North. ) 'ndover Subsurface disposal system check list - Page 2 Fail OK Distribution Boxes Reg.10.2 (a Slope greater than 0.08 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 (6) NoGreater 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 (a Calculations of leaching area (min. 500 S.F.) Reg.14. 3 (b Spacing (4 ft. min. 6 ft. with reserve between) Reg.14.4 (c Dimensions 14. 5 Reg.14.6 (d) Construction Reg.14.7 (e) Stone Reg.14.10 (f) Surface drainage 2% Va� DownhilSlope Slope y/x = (to be shown) (by/x X 150 = (to be shown) Pumpp Reg. 9.1 (a) Approval Reg. 9.6 (b) Stand-by power l � .� _ol S PO ia►L. _, Sys-TEtsA Dfj;,_$kl C?t�I of LoT PfZEPAR�� F OR- •4S t N�lr--r2-'f t FiZA1VIC C Gil �NA4. ANp -T r. EI-ICatt++E_TTL.S 4,tv0 ARLNITEC.TS NoR.TH AtvDOv�R�F�-ILE Po,;L .. r . NOR-«+ Ar+oo..�R ,MA, o�8gs -179 r� I P-i -117 f� I f fiR I � f f a✓1 ` 1 94 1 Aor r' f 00 c im si 1 j i - 4 W DESIGN DATA ' CAL,cULAT1ONS Sol D65 E RVgT IONS aY . t3asZ�3A►4At.e✓a 11V!'Tbitsy i IV!) PERGOLA?lore PEST No. i Z a4 S DA-T E. tI ►3 �S jI BOTTOM- ELtwq-T ION SATURATION --M%95. -- 12" -}9" DRO P- M ms. 112 G" DROP -MINS. Z ` P1:RC , RA-rE -NA1%41N. S011. PROFILE-DEEP Prr No. 1 2 3 4 S DATE 3 )vil, s Top-ELE VATION -TOPSOIL - ---- S U 0501 L __-- ---- --- — ---- - -- PARE NT SOIL - Yr WATER TA3aLE =" I I , Q ' I A-'ER'TABLE ELEVATION BOTTOM ELEVATION BU t D 1 NC-�71CPE --- ___ZB.R.,OR x C*. UNIT s (° O GPD FLOW ro C GVD Flaw X 15U�= 6pD LISE 10� E�►+AL.S!�PTK TANK L£gCHtNGr AREA C,-Po FLOW x ( .S %P/GAt-.= �f SF gab USE 9100 '3F PITS TYP E My it. (- YP, S►DE ALL AREA : SFX GALR.1 SF = GPD P.aOTTONA AREA SF X G0ALS.j SIF sIiPD TOTAL PIT C i-I I R(2ir CAPAC 1TY _ _ _ _ _ _ _ _ G,-PD /PIT GP D F Low ;_ -GPD/PIT- PI1s Rt9b. U6 _PITS TRP-Nc1-1FS SIDE ALL AREA SF LF'�___ I 6,AIrs ASF = GAI.JLIN.F'T. 8 0—rr R EA S F�LF X GALS�S _ lO*TAL` RF- 1 LEACHING- CAPACITY _ _ — _ _ GAL,/ LIN•PT. i GPD Flow �a.�Lut•�r.=�U:.'R vt4t1A MS R243D. USS L.T ! NOT ES : - Q Pi.Vwmeb Pipe aL>wsLJ-. f MOTE: ALL EI.EV&TWNb 7-eFi-2 TO 60-r-rOM 6 _ 5pr��_Tar►�c 1""&T11 0� i�tP>� {tNvlrZ�J L-- �F-c7-r i G TA."V. O+xr L.s-r Q Pti.-ra. �30A 11e1-ST Pte. t - 1-� ��t•.. G K A.x�E C� S E.D � - � ,.� � � + a I _ to F- d a c v F 4= VEt�OZATED C3tTUMLNOt1S - i 3 r � I s F1t3EfL. PIPE (G/lPPEt� ta1NDL� � i /sR//V. ��YE Ot1T,LET i 1 � vrsr,2. J34Ox E t NON— PSIZVOR..b.T150 PE2 OQ.ATtcD LE 4G-HCMG OtD LIMIT Li Niz k V• W n P L 4 M o f N 0 5 GALE -vile /7-lr"r7 1�, ,r '- �r � ,_, `.� r ry� � .• r i 1 i 4 F�- - N-AANHOL.es -m w rrt4(N 4 ozz F:i9tst4 (q;;w\DE t4 1 te Es P,4Ut�plhi.� ve\PE . .-r { C.T -E t! - L r� .r P, t.. DIST _. , L1J J . : t COAL � SEPTiC ThN.i�" ',� I cT ALL- STONE --"ALL i � DE WASNEG . r� : 1 1 -giptical` l.EACHIKgr FRoFtt_.�. R� _FF . FIRWA c • M AT ILD 95 44 OIL + � �• S�It� �i�._.[.�� a" i�+S-���Y%�� .�lr- �-ate � :i��.i� r'r� /l-1'f! �1 _ --�j�kw ,`"fir ���==�,1'�:�� Ii�-I`♦ �� "f"��► 7•Y�� {��� 1�����}��•�3 _� ~1 �,` !gISE ♦ ! ~ +ice'+' �l.t' rli.� :li�r�"�� t��`� =1". � ��s.I_ l� - , 2- `��-Ti�� r"�i- ♦t. ZisY_ -S:YSr� �.'Y�-�.VVVVVVt' / ��. ♦ �_-• ti `, ������.� ♦ � �� ♦ice ♦ ♦ �Q♦ ���♦ �. ��� ♦ �����• � ♦ ♦ ♦ ���� ���� 41 • i • 4 tJ Z W I u;Lr-AC.E DisposAL- Lc>T i t P(Z E PA(ZE C7 F OWL 4S I �cz�vs� C G� ���+A� Arvo Assoc►AT�.s rc C. t F��s Ar+O AptcHITl.-c.-Ts f 1V osz.YH tv0cm,vT--Sz Oc c-%cti RO&V %L �` NoR rta A.t�+aovE-.iz ,Mta 01845 J' 1 � rlrp S4 �a4 fn - ; `7 i ch rr S .r 1 ' - 444 ' w1 Y ' I 1 F � � I t i r -TIE, -►;- t.::rJ I cam' --T- - •�•,•�E•� -C'' "5 _ 1 4 v1 .f'L: 11i I 4 I V I DESIGN DATA j CALCULATIONS • Suit OBSERVArtiION5 BY, - -- r3e�.'3-'3 -o WITNtESS �'a 14P -Pt=RCoLA-TION -TEsT No i 2 —3__-- --4 S taazE 4� ►3 �g , -TOP-ELEVATION (�4 .�' BOTTOM- ELVVA-T ION } 1.17 - ---- _ � SA1'URQT1oN -Mitis. 03i DROP-MINS , 1� i SOIL PROFILE-DEEP PIT No. 1- 3 _4 5 DATE TO_P-ELEVATION t � TOPSOIL. - -- -- — � -- SUBSOIL - _--.- PAR E NT SOIL — - s T- WATER TABLE i TT,, . G WATER IABLE ELEVATION { BOTvom ELEVATION Bu -- S. X , GAL. I o 0 - -_____ �UN T GPD FLOW GPD Flow x 150" _ } C�pD USSc-o CAL.S L�PTK TANK LEACH 1 AICA AREA Q£D: (ter GPD FLOW x .SS F 6�L= �f �= 1 SF 8� USE 9©eJ SF PITS "TY E MFR, (TyP) SIDE ALL AREa GAL.t.( SF = �,PD BOTTOM RF.�► __ SF X — 6ALs.� SF s QrPD -TOTAL PIT _+4 I WC-r CAPAc-rry _ _ _ _ _ _ _ _ GP D /PIT yGP 0 FIpW GPDPIT= PitS REQfl. PITS T�tE1�1 C H ES SIDE ALL _ 1 A AREA _,__ rcrpLS SP = I GAL./UN-FT. BOTT•O REA _ SF/LF x GALS/SF CooAL/ LIN.FT. -TOTAL-TR E 1 LEACHING CApA.CITY _ _ _ -- _ GrAl,/ L1N.FT. GPD FLAW -:— ��,>~�Lr�. .= LF.TRINCIMS R24D. USF-______L.I= NOTES : _ _ _ ----- p,� E of �� { ' 15�ccu Aux Q pwN►g�c5 p, N D'P�: &L.L ALF-V IST 10 H b CZEFr-2 To 13 o-rTOM - — -- - — j'j 3t,PT c. �A n,c IriL.*-r !1 F3 Pt�� �1t`!YEQ�} C, j£PTIG Td.tlK Uvrt-�T� - D dlbTtz. �3ox D�wrm. TL-6T F- J— C F t ru. G RAtae. Cay H ci us E- a .4 e, S Z PS4 FC I i b PE2 F7 _-- _-- _ _ Y -App _ a d G D E 4PEt2-V-09-&TF-D arrumiNoub F � w , ! , � Ft4E� PIPE �GADPEt7 G*tD41 � ' 3 r4m. F/Ytw o/1z4or pjs-ro— Cox { NoN- V0R.ATtrD I..EQLHtMG L'!Ep ' L.1M[T L..! IVL LA } a PL& N OF -L_ ED.GUtMG� D g - G 4 CTE ' ,� E+`EYA _`r,► E R t�VER" fi P " r t SEPT+ '?PNI< INLET S r_P-`1C iA.NK: CUTLET 2 i f 4 171ST 3GW Tial -T r !t5 , B$ ! i G ( s OTTC N4 rJF i i 1 A ESS MAN HO LES TG W a H I P 4 "c ut4N q4--,'ADE --•=-� � --- SAYER ��}tvTR€ATE� A- C = TEES YUIL NG P PF-R . ;, --.- F �js,o _ M%N lt- __.._ _. _ . . . . - F.L. A ._- 2 � +_ { DIST. I--�--_ _ _L - ___ '�8 ' fZ 5TOh1E J ` 1 ^ 1 Q 'd = �S • I 3 LSTONE COARSE SotJp p .4!5 PypicAL LEAcHiN4 H FM A-r t c 0 1�-"a R S ou-r FIMWA &ZA . rIsm Pipe covtot LOAM STOWE 4 oz `,,`�y,i�,�t��� ��_.:.♦i�G=�.��yV,/►a �. ���`�� �!_�J�_•���� �j`i-;�i:•�_'��'�r ��/-.-�f_:•4l�' -�+ti�-. ,`V ,`��">� �l=�T�r�;�r��/�_s�Y� '= ���'t`�js►=���Lif'�' -��� � %��•�i��'t�=~�iC ti jj _ �,`` ,♦ Ci " .:C�{� SS..� y';• ice.-.-r'~lra' �S� �� i.�, - 't � ��� 'ti���� a' �.f f �� -� �. �` ! -� - v tea- / •.r•► ♦ .s' ��.. - � '�' •. / . � _ _. !GT � - ice. - _ 5 G �i w F SusLr-Ac.E DispqsAL. _ SYSTEM DLSIGN o� l._.cy J P SZ E Pa.[ZF--Q F OS- F7-43.4 L C C]E-LAVAS Al`+D QSSOCtAT�S E.NG�tv�TcRS QNp ARC-NIT�CTS NOiZTN ANDavE.R..4���«. PaR�c.. +� V �` NORTH A1`+OOVER ,MA 01845 lei kFdtisEo AP tc.L. it,. 1 ,171 1 { C • �t 1 . r . r r 11♦� dLL A;". ":�� �'.t'. %',rL4 1 I 1 { _ DESIGN DATA 4 CALCULATIONS SOIL.�asERVAT 10Ns E3Y _ _ J. l3dR�3AraA� ;-G7 WITNESS _ L L +_9 PE.RCOLAT ION TEST go. —5--- + DATE 4 I -79 ± r BOTTOM- ELr-VA`T ION -- SA''fURAT10N -M1T1S. S 9" DROP-M ms. V2 G" DROP SOIL PROFILE-DEHP PIT NO. 1 2 3 4- 5 DATE TOP-ELEVATION TOPSOIL - - --- --- —------ SUBSOIL - -- - PARENT SOIL E;► �'. _' �, WATER TABLE " r 4- I, i + WATER TABLE ELEVATION T .' t BC7TT01,/1 ELEVATION 1 - BU I o I N cj-TYP>✓ G44-WAIT GPD W GPD FLOW X 15-00/0GPD USE 1000 0AL.S V PTK -TAAK LF-ACH I NCz AREA G-xa G-PD FLow x 1 .,5' SF/GAL.= c-100 SF ]BOWUS€ `7c�o gF PI-rs � 4 TYP E My R.. (-TYP.) SIDE ALL AREA : _ SF X _ Gr SF = GPD BOTTOM REA SF X GALS. SF s QrPD -TOTAL PIT C" 114% CAPACITY _ _ _ _ _ _ _ _ GrP D /PIT _—GP D F Low ;__ GPD/'PIT= PIM RE 1D. Ube ' _PITS I,tETJCHES SIDE ALL AREASF LFx 1 GALS /$P = 6AL.�LIN.FT. f $OTIC► REA _-SF�LF X GALS/SF = GAL/ LIN.Ft -TC. rAL-M E I I-EAC"J N& CAPAC_ITY A L,/ L 1N.�`T. GPD FLow -1..F.`tRjmcoss Req'D. US€ L.F _- _- PAGm 2 oft 1 _ LL-vDT to m bc-%Aj >UL:'-- 15"c.m N A PLurAoteb Pipe a pws MD?E-: ALL E.LSV&T Wri b -CO iboTTOM OF- 9l VF- (lNVEt-T) 4j• Ci EOT t� Q� I. {- E H T lN. GKAQE � SED � � �' dl � � Z' i{+•-� �II Q t3 G a - ; E 4" PE¢j:-oW.&TED 4tTUMlNOtl9 � � � F1[iErL PIPE. �GQPPfiD G1�ipL) AIN. F/Ye= OVT4ET F 1 i MOM- DERFD R-d►TE d t�+�2FOQp,7Tct� L,g AL-9t 114 G L IKIT L1 NE- I t? PL_&_MoF - L c-AGut HG DER N O S GALE t f 1 cjPltG t� 11 �lQ~at11a .fir( ?- J `4 1-,'E14CW MARK NOT.E ' \Ll StC.) TRLP'ER _ st) «JVER'T OF PT:,F.: FPE Ca I)1NELL ?. 4`_5 Ij !ANK OUTLET 67 ff t i f . i ESS MA,NHQLES Tn waN1N 4 oT: tNt',H q-RADE. 4- T_T TEES P\PFR. ' � 2 y 4 C.I.p i PE _. m a Yom ` . -- - - - - - - 1 } I - i?4_ LF t_ �J S DIST - � = 2g - '/2C sTo t14_ _>< �� S TON E , Vu i �� COARSE c ANG G,4kL j- TIC TA 4K' E wAsHEL_> . ! Hca ' 20 -TYP IcA& LEAs t4o-A ` F'RCl F 11.L -Ca,Lrw — tJI �IrEM AT it. p IVL`T S t-r F U-r , SE'_ pCv, i t • Do COVEK LO `� � 4 � fr• � !fir -' f i. I�:'.. j`� ��r•_ •i s� 1y - - I V17 STONE COALSE lop 41 CrLoss ,',✓! i TTT{t �' :'a.'.�-,rte���'1-' t l';r� �; t�:5�_ _♦ '�= "' i�.!f .- • • i • • lM��`� �;���, ..' r r 1 J _ x { r� w } r r r ,�y �L�.y�►-r � 0 3. INV _ PIPE QUI of HSE. _ _ A �..J V i �.,. 1 A!V DIDE i NIQ T<1A V- 1, %PtPE.ouTvF rc"V— -' ,"i , :.. ; 5► Vim—5 U%t. a 5 pC� 4 W Vi VE u�p.�x = .r.y � SNy E-m1) of Pt Pv-- �` ,p��,t �,{` F'QAN1� GGEL.�tiIAS � ASsc�tA"C'ES J 1c s� .4r�t��.r��z g-r. c�.l v. A►.�cx�tEt� . d r Y � y � t l- l �,L'EVAT � D1•t'sS. � �►5 �`jUt L Ito ., 2111111. arm X14 � �y � -- F'QA�tK GC7'E�-t�.tAS � A,SsUGi•�.TEs Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection William F. Weld Trudy Coxe Ga4emor Secretary Argeo Paul Celluccl David B. Struhs U.Governor t",ommfgioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: •'�-"` ()Va'Address of Owner. Date of Inspection: ,,� `a` c}3—q{p (If different) Name of Inspector. Company Name,Address and Telephone Number. BATESON ENTERPRISES; INC. TEL:(5081475-1474 5-06 ,.L+jS- 414 Excavating-Water&Sewer Lines-Septic Systems&Pumping Service FAX:(508) 375-5451 CERTIFICATION STATEMENT f`V''f 1 1 1 Argilla Road a Andover,Mass.01810 I certify that I have personally inspected the sewage disposal systein 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: _VPasses Conditionally Passes Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �,J Date: The System Inspector shall sub �— mit a cop this inspection report to the Approving Authority within thirty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. e INSPECTION SUMMARY: Check A, B, C, or D: A] SYS ASSE9: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If"not determined", explain why not) _ The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a Fonforming septic tank as approved by the Board of Health. (revised 11/03/95) 1 One Winter Street a Boston,Massachusetts 02108 a FAX(617)556-1049 a Telephone(617)292.5500 A ' Q'Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ' /� CERTIFICAT)ION (continued) �r Property Address: cJ G C.�v�,c. '-e=v Owner. r.��Q V�� 01 Date of Inspection: B)SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the Board of Health): broken pipe(a)are replaced obstruction is removed distribution box is levelled or replaced The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s) are replaced obstruction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: ' Condition*waist which requite+ hu-ther evaluation by the Board of Health in order to determine if the system W(Win l td preoat tho public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER. IF APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: The system has a septic tank and soil absorption system and is within 100 feet to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and 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 less than 5 ppm. 3) OTHER (revised 11/03/95) 2 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: S�j Ci L � �l w,./� N, �[�, Nvx— Owner. ,—�"_`— 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 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. E) LARGE SYSTEM FAILS: r The following criteria apply to large syatems 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 11 of a public water supply well) The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 11/03/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: t0 Date of Inepection:FA a3_ C1 Chock if tiro follows ve been done: t;5ormation was requested of the owner, occupant, and Board of Health. on.of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates durinw4,5at period. Large volumes of water have not been introduced into the system recently or as part of this inspection. t/As built have been obtained and examined. Note if thev are not available with N/A. e fac' 'ty or dwelling was inspected for signs of sewage back-up. _� Thee m does not receive non-sanitary or industrial waste flow fTha s' as inspected for signs of breakout. All By excluding the Soil Absorption System, have been located on the site. The manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or P traize rial of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Gnd location of the Soil Absorption System on the site has been determined based on existing information or �Th.fh,_Wty ted by non-intrusive methods. owner(and occupants, if different from owner) were provided with information on the proper maintenance of Sub- Surface Disposal System. r (revised 11/03/95) 4 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION I Property Address: G(;�, �� L o A , e— Ov�� Owner. 1^ Q \ Date of Inspection: �` ��" `� PJ FLOW CONDITIONS RESIDENTIAL: Design flow: ��ns Number of bedrooms: Number of current residents: Garbage grinder(yes or no):—Te--s L.s4UA", tYAM60*4 to syste.1n (,yea or nv): Seasonal use(yes or no): 1-0 x s a8 s �36s k7£� pq Water meter readings, if available: 4 C100x , - c X18 -t- �C)I = 1 /a = . 5 let /C�V 6W eLast date of occupancy: v COMMERCIAL/INDUSTRIAL. Type of establishment: Design flow:_gallons/day Grease trap present: (yes or no)_ Industrial Waste Holding Tank prrsent: (yes or no)_ Non-sanitary waste discharged to the Title 5 system: (yes or no)_ Water meter readings, if available: Last date of occupancy: OTHER:(Describe) Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: � System pumped as part of inspection: (ves or no)" If yes, volume pumped: gallons Reason for pumping: TYPE OF YSTEM 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) APPR O&M�j�(iE of�components, date installed(if known)and source of information: (� Q"CS ®'A 1-�- V 0 } Sewage odors detected when arriving at the site: (yes or no)!" (revised 11/03195) b r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner. ��V\V" 01 Date of Inspection: 9-qjL' SEPTIC TANK: (locate on site plan) Depth below grade:3 Material of construction: ✓ncrete_metal_FRP—other(explain) Dimensions: 10 — n_ Cz oviS Sludge depth: 1" 0 Distance from top of sludge to bottom of outlet tee or baffle:7.')3 Scum thickness:_1 go r r Distance from top of scum to top of outlet tee or baffle:8 p Distance from bottom of scum to bottom of outlet tee or baffle: �Jr Comments: (recommendation for pumping,conditio of inlet and outlet tees o baffles,,d, ptthaof liquid 1 el ' lat, n t outlet inve stru (nte" , evide of. eakag.1, e .) V V -��� `"�-� � . -� Q k V O G E TRAP.NrSO V\(?�_ (locate on site plan) Depth below grade: Material of construction: _concrete_metal_FRP_other(explain) Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) (revised 11/03/95) 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C rSYSTEM INFORMATION (continued) Property Address: ,jG Owner. Date of Inspection U b� ka-a3-`7b TIGHT OR HOLDING TANICIWVN.0 (locate on site plan) Depth below grade: Material of construction: _concrete metal_FRP_other(esplain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches,etc.) DISTRIBUTION BOX:(/ (locate on site plan) Depth of liquid level above outlet invert: Comments: �l (note if 1 vel arid�distributyn is.equal, evidence of solids ' over, evideence f leakage ' or t o(bo etc.) Li tL C� t C- PUMP CHAMBER (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances,etc.) (revised 11/03/95) 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM d PART C SYSTEM INFORMATION (continued) Property Address: ,56C'C'�� (�� LOV4."Q- 1"/- wl� Oner. "�-- ZSa�>nf 1( x'1 per, Date of Inspection:\';�)-as-c SOIL ABSORPTION SYSTEM (SAS): /1� (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: leaching trenches, number,length:---�— —� t leaching fields, number, dimensions: D YC Y overflow cesspool, number: I C mments: (no con 'tion�of so signs of hydrau;ic f 'urs, le l onding, n vegetation,etc.) CESSPOOLS: f\C)vV (locate on site plan) Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow(cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) PRIVY: AOv�le- (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) (revised 11/03/95) g � q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM ' PART C SYSTEM INFORMATION (oontinued) Property Addreaa: C���L�=�� L-0�. Owner. �Pe �_ Dl Date of Ims tion: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' u.aQy AAn1� rr I �-t-� 3 v Ll a DEPTH To GROUNDWATER Depth to groundwater: _` feet method of determination or approximation: OC<2 - CA—>N • (revised 11/03/95) 9 ,1 Commonwealth of Massachusetts City/Town of DIVED a' System Pumping Record Form 4 DEC 17 2008 DEP has provided this form for use by local Boards of ,Health ` '�xta be use-'d but the information must be substantially the same as that provided I�g-ttirs 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: Left front left rear, left side of house. Right front, right rear, right side of house. forms on the computer, use C only the tab key Address to move your Ui.— cursor-do not Cityfrown r b v C•� State Zip Code use the return key. 2. System OW f 7c�'f- Name ISI Address(if different from location) City/Town State Zip Code Telepho Number B. Pumping Record 1. Date of PumpingDate © 2•.Quantity Pumped: gall 1566 — 3. Type of system: Cesspool(s) 2/Septic Tank Tight Tank Other(describe): 4. Effluent Tee Filter present? 0 Yes ERZNo If yes, was it cleaned? 0 Yes arNo 5. Condition of System: [fame) 1 >� 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: S.D Lowell Waste Water o igna ure of H Or Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 �LN Commonwealth of Massachusetts City/Town of7PR iV a System Pumping Record �M ve ee Form 4 2010 DEP has provided this form for use by local Boards of Health. Oth he information must be substantially the same as that provided here. a- @14ack 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 side of house, Right side of house, Left front of house, Right front of house, Left rear of house i Ft rear of house Left rear of building. Right rear of building. Address A CityTrown state Zip Code 2. System Owner: Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping r — 2. Quantity Pumped: t 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: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locat� contents were disposed: L D Lowell Waste Water qgrptuteofHaul rDate t5form4.doc•06/03 System Pumping Record•Page 1 of 1