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HomeMy WebLinkAboutMiscellaneous - 57 OLYMPIC LANE 4/30/2018 57 OLYMPIC LANE ' 210/106-B-0141-0000.0 s �LN Commonwealth of Massachusetts City/Town of NOV 2 C 2012 System Pumping Record TOWN OF NO�ITH ANDOVER iO Form 4 HEALTH DEPARTMEO 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,Rig re e, Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address n ' t U� � Cityrrown State Zip Code 2. System Owner. Name Address(if different from location) City/Town State Zip Code �'�:�-� C) Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes LSO If yes,was it cleaned? ❑ Yes ❑ No 5. Conditign of System: 6. System Pumped By: Neil Bateson F5821 Name .Vehicle License Number Bateson Enterprises Inc Company 7. Locaf here contents were disposed: G.L Lowell Waste Water SignA9t Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 3 Of,MO cT buO 0 s * Town of North Andover HEALTH DEPARTMENT SAC HUSf CHECK#: DATE: 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) $ ❑ T/itle.5'I6pector $ 42 Title 5 Report $ ✓ Q ❑ Other. (Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer COMMON EALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS d DEPARTMENT OF ENVIRONMENTAL PROTECTION x Y� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve RECENLi) Owner's Address: Same _ Date of Inspection: 12-03-2008 DEC 15 2008 TOWN OF NORTH ANDOVER Name of Inspector:(please print)John Soucy HEALTH DEP' --.,. w r Company Name: Soucy Sewer Service,Inc. Mailing Address: 78 North Broadway Salem,NH 03079 Telephone Number: 603-898-9339 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: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: aw Date: The system inspector shall b a copy of this ins p tion report to the Approving Authority(Board of Health or DEP)within 30 days of comp ting this inspection. the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector d the system owner hall submit the report to the appropriate regional office of the DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving authority. Notes and Comments ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. NOTE: This Title 5 is NOT a guarantee/warranty of the future function of the septic system. r/ r {f Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 Inspection Summary:Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not)is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is imminent.System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box.System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken or obstructed pipe(s).The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: rr Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 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(l)(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 surface water _Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. _The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. 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: t� Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No _ X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool X Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool X Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool X Liquid depth in cesspool is less than 6"below invert or available volume is less than'h day flow X Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number of times pumped X Any portion of the SAS,cesspool or privy is below high ground water elevation. -T Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. X Any portion of a cesspool or privy is within a Zone 1 of a public well. X Any portion of a cesspool or privy is within 50 feet of a private water supply well. X Any portion of a cesspool or privy is less than 100 feet but eater than 50 feet from a private water P P �'Y �' 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 II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat,or answered "yes"in Section D above the large system has failed.The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. 1 Page 5 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Yes No x _ Pumping information was provided by the owner,occupant,or Board of Health x Were any of the system components pumped out in the previous two weeks? x _ Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? x Were as built plans of the system obtained and examined?(If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? x _ Were all system components,excluding the SAS,located on site? x _ 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? x _ Was the facility owner(and occupants if different from owner)provided with information on thero er P P 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 x _ Existing information.For example,a plan at the Board of Health. x 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 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMK 15.203(for example: 110 gpd x#of bedrooms):_440_ Number of current residents: 5 Does residence have a garbage grinder(yes or no):no[recommend removal] Is laundry on a separate sewage system(yes or no): no [if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use:(yes or no): no Water meter readings,if available(last 2 years usage(gpd)):see attached Sump pump(yes or no):des Last date of occupancy: current COMMERCIALANDUSTRIAL N/A Type of establishment: I 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: i Last date of occupancy/use: i OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Home Owner Was system pumped as part of the inspection(yes or no): yes If yes,volume pumped: 1000 gallons—How was quantity pumped determined?Gage on truck Reason for pumping:Inspection and Maintenance. i TYPE OF SYSTEM x Septic tank,soil absorption system 1 _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: 1979 Were sewaae odors detected when arriving at the site(yes or no):No Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Olympic Lane North Andover.MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 BUILDING SEWER(locate on site plan) Depth below grade: 26" Materials of construction: x cast iron _40 PVC other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK: x (locate on site plan) Depth below grade: 34" 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: 816"x 418" Sludge depth: 2" Distance from top of sludge to bottom of outlet tee or baffle: 38" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 7" Distance from bottom f " o scum to bottom of outlet tee or baffle: 14 How were dimensions determined: Tape&c Sludge Tool Comments(on pumping recommendations,inlet and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet invert,evidence of leakage,etc.): no leakage GREASE TRAP:_(locate on site plan) N/A 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.): e, Page 8 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12.3-2008 TIGHT or HOLDING TANK: N/A (tank must be pumped at time of inspection)(locate on site plan)N/A 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: N/A (if present must be opened)(locate on site plan)N/A 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.):This is a PVC 4"type distribution system,found no D-box in this system.By non- intrusive measures(camera used multiple times,along with cleaning pipes).Consulted with local Town and State DEP. PUMP CHAMBER: N/A (locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc) Page 9 of i l OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 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 trenches,number,length: x leaching fields,number,dimensions:20'x45' 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.): CESSPOOLS: N/A (cesspool must be pumped as part of inspection)(locate on site plan)N/A Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): Comments(note condition of soil,signs of hydraulic failure,level of ponding,condition of vegetation,etc.): PRIVY: N/A (locate on site plan)N/A 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(continued) Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 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 where public water supply enters the building. �• L - •t ' { MK Page 11 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 57 Olympic Lane North Andover,MA 01845 Owner's Name: Howard&Brenda Reeve Date of Inspection: 12-3-2008 SITE EXAM Slope Surface water Check cellar x Shallow wells Estimated depth to ground water 6" Please indicate(check)all methods used to determine the high ground water elevation: _Obtained from system design plans on record-If checked,date of design plan reviewed: x 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: Dug hole with auger in low drop off area. I Dec 05 08 02: 46p p. 1 Summary Record Card generated on 1215/2008%42:54 AM by Karen Hanlon Page 1 Town of North Andover Tax Map # 210-1063-0141-0000.0 Parcel Id 17545 57 OLYMPIC LANE REEVE, HOWARD 57 OLYMPIC LANE N. ANDOVER, MA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1 Acres FY 2009 UB Mailing Index Name/Address Type Loan Number Active/lnact. From Until REEVE,HOWARD Payor 57 OLYMPIC LANE N.ANDOVER,MA 01845 UB Account Maint. Account No Cycle Occupant Name Activelinactive Bldg Id. 17501.0-57 OLYMPIC LANE Last Billing Date 101212008 3170171 03 Cycle 03 Active UB Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63518 7.82 1t WTR WATER 01 ALL METER SIZE 75.99 /1 UB Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 16544153 a Active ERT HH ME ,E-METE - w Water 0.63 0.63 41 Date Reading Code Consumption • Posted Date Variance 9/9/2008 604 a Actual 22 10/10/2008 4% 6/5/2008 582 a Actual 19 7/16/2008 7% 3/11/2008 563 a Actual i 19 4/11/2008 -26% 12/10/2007 544 a Actual 27 1122/2008 10% 9/412007 517 a Actual 25 . 10112/2007 21% 6/15/2007 492 a Actual 24 7/20/2007 6% 3/13/2007 468 a Actual 22 4/16/2007 -11% 12/12/2006 446 aActual 23 1/19/2007 18% 9/18/2006 423 a Actual 22 10/20/2006 -2% 6/14/2006 401 a Actual 23 17/10/2006 -6% 3/8/2006 378 a Actual 19 4117/2006 10% 12/22/2005 359 a Actual 21 1/17/2006 -44% 9/21/2005 338 a Actual 35 10/14/2005 76% 6/27/2005 303 a Actual 24 7/15/2005 6% 3/15/2005 279 a Actual 20 4/5/2005 6% 12/13/2004 259 a Actual 18 1/14/2005 -20% 9116/2004 241 a Actual 22 10/8/2004 24% 6/22/2004 219 a Actual 14 7/3012004 3% 4/15/2004 205 a Actual 25 5117/2004 0% 12/12/2003 180 n New Meter 0,1 12/12/2003 0% Commonwealth of Massachusett RC1 L '\\, City/Town of a System Pumping Record �" q1Q Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DER has provided this form for use by local Boards of a er 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 UQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health of�ottter approving authority. A. Facility Information 1. S stem Location: Left side of house, Right side of house, Left front of house, Right front of house, eft rear of house ght rear of house. Left rear of building. Right rear of building. t Address5 / l e-,�f �J „ Cityrrown —State ,(�--�'(/`- Zip Code 2. System Owner: Name Address(if different from location) Cityrrown State/1j//], r��+ //�7/ 'Zip Code 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 ffNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System- l 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location ontents were disposed: L.S A Lowell WasteWater. Signature of H ule Date t5form4.doc•06103 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts City/Town of E 'JVED U System Pumping Record �, � 19 + �� Form 4 TOWN OF NORTHND DEP has provided this form for use by local Boards of Health. th � y� � ,Put the information must be substantially the same as that provided here. Be ore usl , 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 Rightliiof ho Left/right side of house, Left/ Right side of building, Left/Right front of building, Left/Right rear of building, Under deck Address 5 ,y-, (� ��� City/Town l//J State v/lv/ Zip Code CJ 2. System Owner: Name C� Address(if different from location) City/Town State/ �5—tom d ode Telephone Number }vim B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) 919eptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes No If yes,was it cleaned? ❑ Yes ❑ No 5. Condition of,System: ( � V"- 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Lomcation tents were disposed: . Lowell Waste Water Sign toe Haule Date t5form4.doc•06/03 System Pumping Record•Page 1 of 1 TOWN OF NORTH AN'DOVEk UA I.k SYSTEM PUMPINQ FL$CO}j, SYSTEM OWNQR do ADDRESS T17EM A�� IV � — e-,Ve aZ- DATE.OF PUM�1Nq / z -- ._QUANTITY P YES 50PUC 1'knk: NU YES N^ rUKU ON SERVICE: KounNe Ub��RVA'P1UNJ: RECEIVED OD CONVITI PU OOL! 'ice COVER oRAVYOT3 ORWB __ BAPPLSS IN PLACL, JUN 4 3 2005 6�C13SS7VB SOLJpS . ._. L6hCHP1L'1,D RUNBACK ,�..... SOLID CARRYOYLR— . 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Jp Co V ... •, ..'j: :iwY�.i,j..tl'ij: .�I!1• .`w(i;, .. / � l .\• .• , " `' Telephone Number ..r�, '•-.i1'„ .:`' is f• kB !Pum: Lt�g Re.�ord t:'1 SI,N'•'.,1•, r. tq°of Purnpinq,r '''`'' 2, Gluan of :•'• Da tlty Pumped: Gallons :`,Typo 91,aystam •; ❑ Cesspools) Septic Tank ❑ Tight Tank ,..•x:1;1,.:! 1 ' �11!' .'+'.,Y •'��. •'Z�� ' • Y,:i 1.. .11;1., „ :1'1, •' .. . '"' � ;�]�Other(describe '.`;••',. , • •:�`'I'i' �,, I.r Yt1�r d .jr.�''r.:l•ii!'. n,��� �••'•1 r • :Y. .�., ;i:, �;t;: :" •{•f4��ll�'rir✓•�I:�i, t!Y,'7,pP �ti1!t Y ,t� ani.' '��• ,:' K�•I ' Effluent Too Fllte{,prosen•,t?.0 Yes No if s If cleaned?1frr,:(o�� it � yes, Was ❑ Yes ❑ No .:�iC,. •' ..'i: '.1y�Jlriil!.\Y:IIdYf�m;,�IgJ.1}}''n'L`'iltl.h t;'i':1 '`i - "^;.; hN!::,-;°!; , :Coridi�lon �' ..r',,h�;<�`1 r 11%h �i•+l:r;''Y';VJlty,'la'di i+4,S:'� Y.{1 U illi;' •�' 't(; 'l., .111• 1Y' ::� .w1.�•L� .nrJl,ulll.{.w't�•',.i�`�1.'1 !•�' '''��'Q� P roped �. ,;,. . . :: •�,.• •' •�'J\i•[al,•r,::•r;..l�i'•':%i alttie'1\'41;r 'J.• `' y , •,.:i:iw•� ,.v. +:;t•�, ;>/,,; j: lj,�""1 1 :''n,�' y •,lt•v' :;r:''.., VehICJ t.l � e cent Number •yam•:.; :.,.� �.4 .•�Y1,rj�1�/;`•,.b •r"•`tlry.rw��A J'1 t •,.V:C'1'(;�',�;:�'',t, _ •.�`r�`��`' ,;�•':'.�':�;,4r'.;:,3;7;�>:l.oCa on;where Gorttbnt�,Were:dl�posed; ' il i.-v.j �t•'4,.•Ji,%'i<l � :r A,1/ �....�yp1'""1:</'J•I 11 •tY .l,,h}�yy�i•�. t:i�'v:i�?�.�•.13na :.1: .��yri.,` ,,;, � r.•.Y�i�., :1 J 1":,I ,�l..:i ., ,!,f, •Yi �: +`•4 ;i...f V . ':• �:'.�:.L �•jy:�j�''Jrtli•�•i�d7inF�r1l, Ij• 1. C '::r'w� ' C/ :•,;. :,;:,::;;;i�;sa'.?;• SYY",:;;!,.8b� f Of HiUl�(;i 1:, �,r:l ,••„ .Y• , ,. ,1il,, t pate y' 'hUp'Avwwlmass.goWde afe�/�pprovaJsJ't6fo,rms,htm#Inspect `r•�' ..t ;,' Syslem Pumping Record Page 1 or I N STIIaART'S SEPTIC TANK SERVICE )ZG Main Sf. 47 RAILROAD STREET n/d i4h A BRADFORD, MA 01835 Ll.wul Lac 1S/ -cb 1.1 978-372-7471 Lac mmm OF ©G( b er MOM= REPORT FOR TOWN OF �C3 AhyN r DATE ADDRESS GAM DNS OaftTPS grid(e- / 0 -16 e-0 `16 q3 9 1D-/ X75 win le 03 50 3.3 7 I ( o r 53 Aloir;vo r �- Commonwealth of Massachusetts `-RECEIVED City/Town of System Pumping Record s`' 1 J 2014 Forth 4 TOWN UF-NURR1-H ANDOVER HEALTH DEPARTMENT DEP has provided this form for use=by local Boards of Health. Other forms may e u e 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 hous , e Righ of hous Left./right side of house, Left/ Right side of building, Left/Right front of building, Left/Rig rear of building, Under deck Address City/Town State Zip Code 2. System Owner. P e e�Q-` Name Address(if different from location) City/Town State- Telephone Number B. Pumping Record 1. Date of Pumping bate 2. Quantity Pumped: Gauons 3. Type of system: ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Other(describe): 4. Effluent Tee Filter present? ❑ Yes 9-90 If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition ofste : 6. System Pumped By.- Nell y:Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio where contents were disposed: I`S. Lowell Waste Water -- � SignAU64-H—aulerU Date t5fomi4.doc•06/03 System Pumping Record•Page 1 of 1 II 4 � / rf ?OV�D �f_�rE ; z." P ROVED ��TF, �.•v t r 1/7 A IL Ox ?- `4 . Di stance .To: `,`etlands Drains Well 2, ly'ater Line Location �. PVC pipe 0•. Septic Tank q Tees - Length & To Clean Out Covers LI -Z.- Cem , Pi e to Tank - On Both Sides of Tank S. Distribution Box / Cover & Box - No Crac'rs All Lines Flowin- Equal Amounts i-.To Back Flow Y_ . Leach -,field or french D.•. ^ensons Stone Depth Capped Ends Clean Double V: ached S'.'one 7. Lear': Diriensi(PIs Stone IDlepth Spl Pads Te�s C�rent Pipe to pit - Both Sides Clean Double Washed SII-one f 8., No Ga..»',af-e Dis-oosal q.. sinal _: ad-*Lnq Insnechion r' -10. Barrac .. 3ing Co-,,Te--. ed System Gf 11 . As - Built Submitted 6 Lot Location Dimensions of System Location __th i ecard to t :c c Fest Elevations t:'aI.er gable SUBSURFACE DISPOSAL SYSTEM CHECK LIST NORTH ANDOVER BOARD OF HEALTH AIBP OVED DATE PROVIDEDp ¢- 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 ,l.ot //,abutters) (Planning Board files) location and log of deep observation holes-distance to ties cation and results of percolation tests-distance to ties esign calculations & calculations showing required leaching area location and dimensions sf system (including reserve area) existing and proposed contours location of any wet areas within 100' of the sewage disposal system 01- disclaimer (check wetlands mapping) surface and subsurface drains within 100' of sewage disposal system or disclaimer i location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) 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) location of benchmark driveways garbage disposers o PVC is to be used in construction a profile of the system (elevations of basement , plumber: pipe septic tank, distribution box inlets and outlets, distribution field piping and any other elevations) maximum ground water elevation in area of sewage dispose . system 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 10' from cellar wall or inground swimming pool 25' from subsurface drains A North Andover Subsurface disposal system check list - Page 2 _ .AJ Fail OK Distribution Boxes Reg."10.2 Slope gr6ater than 0.08 Reg.10.4 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 e 2"f2'x4" P(ask P� -( Leaching Fields ��� p+ � Reg.15.1 a RoGreater than 20 minutes/inch Reg.15.1 Area (minimum 900 S.F.) Reg.15.4 Construction of field Reg.15.8 Surface drainage 2% Reg. 3.7 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.14.1 0 (f) Surface drainage 2% Downhill Slope Slope y/x = Ro o be shown) b) y/x X 150 = be shown) Pum r@ Reg. 9.1 (a) Approval Reg. 9.6 (b) Stand-by power s SOIL PROFILE & PERCOLATION TEST DATA Town/City_0p. ANQ, No.&Street 0L�j M PIC. (...NA) F�Lot No. Loc./Subdiv. lOC-) j Is CQ0SSjtj6Plan Owner Investigator AG,& L-t_n Observer-7z CvS E+Itr lG- / PC C-7f7l�_I-( tj SOIL PROFILES-DATE S( j 8�-7-7 9 h I--��- 1' lev. t Elev. 3' Elev. L_-Elev. 0 S lS 0 0 0 1 1 1 1 22 2 2 ��NE �(�l L Q�t✓ 3 3 3 3 d�a� X60 4 4 4 4 L, T 5 5 o Bot t E� 5 5 o -TILL_ Lo ' 3-7 6 6 6 6 t_ 7 Qm 66C> 7, 7 7 r 8 8 8 8 + 9 9 9 9 10 10 10 10 Benchmark Location Elevation Datum Percolation Tests-Date Pit Number 1 2 3 4 S Start Saturation Soak-Mins. Start Test-Time Drop of 3"-Time Prop of 61'-Time FAL D Mins. lst 3"Dro II.I Notes & Sketches on Back Frank C. Gelinas & Associates, North And. {stet (r:S7 #Z 7-0ZE t O c,gTsA My S u civ Ey , c TN ,4IJ =S� /� M lm w c�Q��//tit F t 2 M t c• 4\ Tri neT Ute' f" �Q IIS .�n.�'( d"1 9-/`-711 1 t I 1 1 i � r 1 l i 1 i I lr r *,�! PIR'F, our nF {•jet= 70 + I-hav-RIFs Cu I OF wAA 'hlV-PIP-- OUT