HomeMy WebLinkAboutMiscellaneous - 638 FOREST STREET 4/30/2018 638 FOREST STREET
210/105.D-0013-0000.0
i
.C-\ Commonwealth of Massachusetts L
ECEIVED
City/Town of
System Pumping Record NORTH ANDOVE y p 9Form 4 F NORTH ANDOVER
TH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms mae
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
When filling out 1. System Location:
forms on the �, 1
computer,useonly the tab key Address /
to move your ---
cursor-do not State Zip Code
use the return CitylTown
key. System Owner:
2.
y �
Name
Address(if different from location)
--- n
City/Town slate Zip Code
9 X381 ----
tMephon6 Number
B. Pumping Record 9
1. Date of Pumping —��—ate — ) 2. Quantity Pumped:
DCanon—` '� ---- ---
3. Type of system: ❑ Cesspool(s) M/Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes [/No If yes, was it cleaned? ❑ Yes [/No
5. Condition of System:
6. System Pumped By:
Name vehicle License Number
Company
7. Location where contents were disposed:
- �renceJ-� D
-- - ----- —
Signature of Hauler G a–te
Signature of Receiving Facility Date
t5form4.doc•03/06 System Pumping Record•Page 1 of 1
` EIVEO
� Commonwealth of Massachusetts c�12
TOWN OF NORTH ANDOVER
City/Town of HEALTH D gRTMENT
System Pumping Record NORTH AND
Form 4
h DEP has provided this form for use by local Boards of Health. Other forms may be used,but the
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use.The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility information
Important:
1 S stem L cation:
When filling out Y
forms on the
computer,use
only the tab key Address
to move your
_ - - _
cursor-do not City/Town Sta Zip Code
use the return
key. 2. System Owner:
Name
�^ Address(if different from location)
- State Zip Code
City(Town ---- 8�
Telephone Number
B. Pumping Record
2. Quantity Pumped: Gallons
1. Date of Pumping Date
3. Type of system: ❑ Cesspool(s) eptic Tank E] Tight Tank E] Grease Trap
❑ Other(describe): -
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of Systte i
6. System Pumped By:
-•- Vehicle License Number
Name
--
Company
7. Location where contents were disposed:
- M - r
Signature of Hauer oVfi
_ _ _ - r� s
Signature of Receiving facility Date
15form4.doc-03/06 System Pumping Record•Page t of 1
Commonwealth of Massachusetts RECEIVED
City/Town of
system Pumping Record NORTH ANDOVFIR � L 2014
V Form 4 TOWN OF NORTrf ANDOVER
y provided this form for use by local Boards of Health. Other forms �t)e'u�ed),byuWlieAENT
DSP has Before using this form"check wth�yot
P here.
that provided
information must be substantially the same as P Record must be submitted to
The Sy
local Board of Health to determine the form tauthority within 14 daystem s from n he pumping date in
the local Board of Health or other approving
accordance with 310 CMR 15.351.
A. Facility information
important. 1. System Location:
When riilino out y
s
forms on the
_.
computer,use -only the tab key Address
olqs-
to move your City/r14 ,_ zip Code
cursor-do not State
ows
use the return
key. Z. System Owner:
-
vErn
Name
Address(if dAirent from rotation)
—.- -.
-- - Stat
2qQ Zip Cc de
City(rown ._-
Telephon Number - --
s, Pumping Record
2• Quantity Pumped: Gallons
1- Date of Pumping Allaie
3. Type of system: ❑ Cesspool(s)
Septic Tank ❑ Tight Tank ❑ :Grease Trap
❑ Other(describe) - - --- __
4. Effluent Tee Filter present? ❑ YesC�g-No If yes, was it cleaned? ❑ Ye,s j><No
5. Condition of System:
6. System Pumped By:
__--- - - - -- - Vehicle License Num er
Name
company • •
?. Location Where contents w •
Date
ignature of hlau -
_
Signature of Receiving Facility
System Pumping Record•Page i of 1 /
15form4.doc•03106
Commonwealthof assac usetts RECEIVED
Zlj City/Town of k40%e
System Pumping Recor / 'JUL 3 12008
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
Important:
When filling out 1. System Location:
forms the ��� "Fo Ce s� 37
computer,use
only the tab key Address
to move your Nor�h Ao c)yefM(j ()1�' Lt
cursor-do not City/Town State "1 Zip Code
use the return
key. 2. System Owner.-
fm_'ycr1 �Ckr dc's
Name
lC � Address(if different from location)
City/Town State Zip Code
q-�F- gas- 33g I
Telephone Number
B. Pumping Record
1. Date of Pumping Dat a 2. Quantity Pumped: Gallonnss o0
3. Type of system: ❑ Cesspool(s) []Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes VNo If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of(fSystem:
00
6. System Pumped By:
Jim Gal tanJ
Name ,1 Vehicle License Number
\V^V( �eC �ny i _()nM
o n m�n
Company
7. Location where contents were disposed:
nz�.D.
Lawrence, MA. -7--a5- 06
Signature of Hauler Date
Signature of Receiving Facility Date
t5form4.doc•03/06' System Pumping Record•Page 1 of 1
t
Form 4 -- System Pumping Record
Commonwealth of Massachusetss
: Massachusetts
System Pumping Record
System Owner System theation
Id !' t . ! io F r*...t .:t
1,,rth tndov-r .,rth hndovor HA. 01,14',
X7$1 7-1`
-- ----------
Type: Emergency Routine
Cesspool: No Yes Septic tank: No Yes
Date of Pumping: Quantity Pumped: r "Ions
System Pumped By: Wind River Environmental, LLC Permit##:
Contents transferred to:
' 7 lk-"A
Contents Disposed at: �
�I
Date: Pumper signature:
Condition of System/Other Comments
Dep Approved from - 12/07/95
Address _!0-23 . t::'61-- �j Title of File Page of
Date File Open: Date file closed:
Doc Document/Action Title Date of Refer to other Purpose of Document/Action and notes:
action Document/ document/
Num. Action Department
Board of Appeals — Board of Health — Planniing Board — Conservation Commission — Building Department
4
` 164.
W
w
O„
1 ,
zz
28, 1500 6AL TANK
Z• 3
5 (
rXIS IN& NSE.
J�
a
OT lA
s.WtrGL GOGAT/ON °, �''' i •
s
S X38
E F T
E L E: VAT
Pe sl 6�1 A S �IJFGT
tmv r-PlDG ouor HsE--- __ - -/pC,•rao 99. 94 INv G�p _rt�lro fANK gip• 83 I 99, 93 j
it-IV P,Pg: 0uforTAN1
99.53 t 98 96
INV. PlPC ttyro D. e)ox Q9' 9�' ��' � rJ U L T
ntv. P E p o
99./7
v Et�to- or P1 pgS 4'9.00 9� 3S S PO -SQL~F_ d
WAT E 2 �- 4.�L7 - t- �4•GAO J i S T E
AVE PAGE ST'oNE Jam . IIII• J I � �
PRop
1VORT1.1 A lv o o v6 p , Ma •
IVv�E = TH/s R'.�,t/ ./� N�t'A WAkt,7N7Y c�F Th'� F OFL
M A VERlFyrATIcN oF' ;KE LockT/o r/
ar THF_ E'X/. /NCS sTr.v�.r'ur/:s- 3 e� vF- L.o PHe Al r
scAr;15- = 3D Oa-rte ;///Z8
REV. WELL LDGAT/ONREV. ///9/54///9/54/'
Chi,Q/STIAN5EN GNGtNCE7RttV0.
a
//4 KENOZA AYE. NAVEpw,LL MA.
� 83 DSD
Boardof Health - Ol.
"A._A-j
Nart}: ndover,MaBs
SUBSURFACE DISPOSAL DESIGN CHECg LIST
.-LOT ` e-T '
APPRO M DATE DISAPPROVED DA'Z'E S'
Provided* Reasons!
i � lam•/�� ,��z� ��''�'
Title V FAIL OE`
'Reg 2.5 The submitted plan must show as a minimum:
a) the lot to be served-area,dimensions lot #,abutters
jw` location and log deep observation hoies-distance to ties
location and results percolation tests-distance to tiescalculat3o & calculations showing ro4uidesign red lesaching area
ns) location and dimensions of system-including reserve area
) existing and proposed contours
(g) location any wet areas within 100' of sewage disposal system or
disclaimer-check wetlands mapping
(h) surface and subsurface drains within 100' of se-w-age disposal
system or disclaimer
(i) location any drainage easements within 100' of seu-Aga disposal
system or disclai.tr—er-PLvuLing Board files
�6) kno= sources of -.ester sLMply within 2001 of sewage disposalle a
system or disclaimer
( ) location of any proposed well to serve lot-1001 Brom
1)
l
e �g f
acilit.
location of water lines on property-10 from leaching leaching
✓ ) location of benchmark
✓( driveways
�) garbage disposals
600 no PVC to be used in construction tic tank...
°-� (4) profile of system-elevations of basement, plumb, pipe., s
distribution box inlets and outlets, distribution field piping and
Other elevations
C� ma}3anm ground ,,ater elevation in area se�.age disposal system
s) plan must be prepared by a Professional Bhgineer or other
professional authorized by lax to prepare such plans
Reg 6 Sept ic Tanks
(a) capacities- 50% of flog, Fater table, tees, depth of tees,
access, pining
(p) cleanout
(c) 10' from cellar ,-all. or ingro�d sig Pool
d) �5, from subsurface drains
Reg 1092 Distribution Boxes
a) slope g.eater than 0.08
Reg 10.4I b) sum
oa �•N R.r 't�lo`e►•�, ��" c°a 'D��cri Na,'K.LR i
I
Form 4 -- Syste All Record
Comm nweaK of#1assachusetss
#Wssachusetts
System PumpinQ Record
System Owner System Location
1)r
MA,
'tr
Type. Emergency Routine
Cesspool: No Yes Septic tank: Noyes
n
Date of Pumping: Qua""Pumped: n pGallons
System Pumped By: Wind RlVdr EMMM041 UC Permit#:
Contents transferred to:
Contents Disposed at:
Date: Pumper Signature:
Condition of System/Other Comments
RECEIVED
AUG 0 4 2004
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Dep Approved Form 12/07/95
Board of -Health
North W-0verzHaas. SEPTIC SISTai {
INSTALLATION CHECK LIST „ Lot. jl
r l
CNID D Dcl SAPPr2cm
AVA OK-11, FAIL
• //• 883oT13t
IV
FAIL OK /til JJ r43a
1. Distance Tot
a. Wetlands.00
b. Drains
c.. Well
2. Water Line Location
3• No PPC Pipe T
/� `'
?�. Septic Tank
a. _Tess -_Length & To Clean Out Covers.
b. Cement Pipe to Tank On Both Sides of Tank
5. Mstribution Box �� �
a. Covers & Box No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. - Leach Field or Trench
a. Ddmensions
b. Stogie Depth.
c.- Capped 'Ends
d. Clem Double Washed Stone -
7• beach Pits
a.
Dimension
b. Stone th
c. Spl Pads
f d. s
e Cement Pipe to Pit - Both Sides.
Clean Double Washed Stone
8. No Garbage Disposal
' 9. Final Grading Inspection
10. Barricading Covered System /
11. -As Built Submitted
a. Lot Location - �Q _ t . F,.f
b.---Dimensions-of System .
` c. Location with Regard-to Pere Test
d. Elevations -
'..- e.' Water Table
f
3:0 A
Board of Eealth "' t
North ',ndoveryma s "714
gQgSUSFACE DISPOSAL DESIGN CHECg LIST',
DATE DISAPPRQVED � J�
APPR�tjNpID� Reasonss
Title V Fes' CE
Reg 2.5 The submitted plan must show as a adons is
a) the lot to be served=areascbl ions lot ,abutters
b location and log deep' observation hOles-d -cta°ce to ties
(� c location and results .percolation tests-dis .,ance to ties
design calculations &'calculations shoring .�cruired leaching area
location and dimensions of sgstem-including reserve area
existing and proposed contours
g) location any vet areas -Atkin 100' of sere df mesal SYSt. or
disclaimer-check wetlands rapper
(h) surface and subsurface drains within 100' of Sewage disposg,
system or disclaimer
(i) location any drainage easements vitt * of serge di sPsjsal
system or disclair-er-planning Board files
3) kno= sources of meter supply Within 200' of sewage disposfL e ,
system or disclaimer • from lead Sacil
( ) location of any. proposed Hell to serve 10..-100 g
1) location of later lines on propexty-10' Brom 19�ach'zg,^facL
location of benchmark
driveways
o garbage disposals -
_--- ) no PVC to-be used in construction
(q) profile of system-elevations of basements plu P Fi4pe, sepc - s
® distribution box inlets and outlets, distrlbe2tn �`J:eld pi '�g md
®cher elevations e alis_A�sal syr
maxi=m groimd later elevation in area se g
s) plan mast be prepared by a Professional Fnglne3er or other
professional authorized by law to prepa'e scT plans
Reg 6 Septic Tanks
a) capacities- 50% of flog, kater table tees1 th ,pf tee f�o
access, pumping
( ) cleanout imd --ng ��
10' from cellar ,,-all. or iugro
d) 25' from subsurface drains
Reg 10.2
Distribution Foxes
a) slope greater than 0.08
Reg 1004 b} stimp
•^' mat
SvS vt rel v S For " _S77- in+ l -6jZ-3yld
- - - - - -_- -- - --- -=mac�T- - G_-��--- - --- - - �� Cc�►w�- --- -- -- -
r /
eLe�-L1 ,
' .. SOIL PROFILE & PERCOLATION TEST DATA
t
North Andover, Mass. Street No 111Jr �c�'¢-ES'�' t ( e.C..�� Lot No
Loc/Subdiv. Pland Owner lvc_o t i F•o
Investigator Observer ISS Z-
SOIL PROFILE DATES
l Alev 2.Elev 3.El ev 4.Elev
0 1— k O 0 O
1 1 1 1
Ties Pits est
2 2 2 2
3 3 j 3 3
4 4 4
ef
5 5 5 5 A.ssso S��
� BF �,or�,Fuer�ED
6 6 6 6
7 7 7 7
8 8 8 8
9 9 9 9
10 10 10 10
Benchmark Location
Elevation Datum
PERCOj,ATION TESTS
DATES
Pit Number 1 2 3 4
Start Saturation
l�
Soak-Minutes
ar e
Drop of 3"-Time
Drop of 6"-Time
MQms.Ist 3" drop _
Mins.2nd " Drop
Percolation �j
N�
FORM 4- SYSTEM ITNUIL\G KECOIW
3
F
t�
Conunoniveaith of Massachusetts TAW8op �!°pF HEAL��
Massachusetts =r
4-
i
i •
Systerrt PuntJ�t rtg Kecvr
4
ys m ��i�pr ��stem--Location
Q
1 Irl UQtitlt, Pumped!
Date of Pumping
6 .,. t
Cesspool: No , Ye ❑ ticT tt.� Yes
P
System Pumped b%-: Ca License #:
Contents transferred to: `
Date Inspector
s
c6t
Commonwealth Of Massachusetts TOv�N NORTH ANDOVER/
Executive Office of Environmental Affairs BOARD OF NEp►LTH
epartment of
Environmental Protection e 2
Wllllarn F.Weld `.i
Governor
4,4.
Trudy Coxe ``
Secretary,EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION '
Property Aridressr H01( ,A_' 'Sj% , J-)OA `�Q_VOf Address of Owner:
Date of Inspection: ) U ^ (If different)
Name of Inspector: ��� ja}�{✓<�J�
Company Name, Address and Telephone Number: C "P./
CERTIFICATION STATEMENT CEhlJC"a �
1 certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
arid 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:
&�
_ asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fail
Inspector's Signature: ^ Dale:
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 design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the repnrt to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A) SYSTEM ES:
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 riot 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 lank as
approved by the Board of Health.
(revised 8/15/95)
One Winter Street • Boston,Massachusetts 02108 • FAX(617)556-1049 • Telephone(617)292-5500
410
J Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: G�U
Owner: . o
Date of Inspection: f c)r 9
,t
BI 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
CI 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 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:
o;„- systc;, and is within 100 feet to a surf2� wa'e• surnt,. or t.ih.:r,7.
surface water supply.
_ The s�,slem 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 Iw5 a septic tank and soil absorption system and Is less than too That bot 50 foot 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.
DI 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.
2
(revised 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 1 V
Owner: M
Date of Inspection: d 1� �V\C ) �Z
D) SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s),
Number of times pumped
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
Any portion of a cesspool or privy is within a Zone I of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply well.
Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from.a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E) LARGE SYSTEM FAILS:
The following criteria apply to large systerns in addition to the criteria above:
The design flow of system is 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety
and the environment because one or more of the following conditions exist:
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area (IWPA) or a mapped Zone II of a
public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 8/15/95) 3
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:638 �`• �
Owner:
Date of Inspection: �'�� d
Check if the follo ing have been done:
G'_ un ing 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
�;?rbu
1g that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.lans have been obtained and examined. Note if they are not available with N/A.
Ior dwelling was inspected for signs of sewage back-up.
g I g
k l"e s tem does not receive non-sanitary or industrial waste flow
he site was Inspecled for sign$ of bwakout.
_All system components, excluding the Soil Absorption System, have been located on the site.
�11111ptic tank manholes were uncovered, opened, and the interior of the septic tank was inspected (or condition of baffles or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth.of scum.
_Tsize and location of the Soil Absorption System on the site has been determined based on existing information or
approximated by non-intrusive methods.
�111falility o,•.nr: (and occupants, if diff(,rPrn from owner) were provided with information on the proper maintenance of Sub-
Surface Disposal System.
(revised 8/15/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
JSYSTEM IN ORMATION
Property Address: � �� . 1� ~ (JeAr
Owner: (� `�
Date of Inspection: Q ✓ (�
10
FLOW CONDITIONS
RESIDENTIAL: `���
Design flow: �a Rallonsj —aS bo ,
Number of bedrooms:
Number of current residents: 3
Garbage grinder (yes or no):V
Laundry connected to system (yes or no):Y-O
Seasonal use (yes or no): No
Nater meter.readings, if available: �t
Last dale of occupancy:
COMMERCIAUINDUST RIAL
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)_
%•Vater 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 pan of ins ection: (yes or no)
If yes, volume pumpe€l tg oa gallons
Reason for pumpingi l lt\ (SQL 6—-td
TYPE O 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)
APPROXIMATE AGE of all components, date installed (if known) and source of information:
tL,Pr eka-�-.,
Sewage odors detected when arriving at the site: (yes or no) �jO
(revised 8/15/95) 5
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: ICJJ U �Fea� �. W.
Owner: K�, —I Q o1Q��l
Dale of Inspection:
SEPTIC TANK:u'
(locate on site plan)
gratfe.
14Is41.1 cjuexs
Depth below
P
Material of construction: LI-Koncrete _metal _FRP —other(explain)
Dimensions: 10
Sludge depth:_ " Ilii it
Distance from top 'frlludge to bottom of outlet tee or baffle:
Scum thickness: .�
Distance from top of scum to top of outlet tee or baffle: �t
Distance from bottom of scum to bottorn of outlet tee or baffle: (7
Comments:
(recommendation for pumping, condi n of inlet ar outlet tee or baffles, depth of h*d evel in r lation to outlet invert, s ru tura♦
integrity, a ence of leakage, tc. u w` Q ,
` 6
k .
Csj tZ 1 VV f
GREASE TRAP:V\OVf,
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP _other(explain)
Dimensions:
Scum tluckne_c.
Distance from top of scum to top of outlet tee or baffle:
D!!13,1ce Itom botto", tint(nm til (it), e! let• pr 1Wllll•.
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 leek,+gen etc.)
(revised 8/15/95) 6
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:.
Date of Inspection: �\ \
tC) SLS
TIGHT OR HOLDING TANK:
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow: gallonshlay
Alarm level:
Continents:
(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:
(note if I gel 4nd dis ributit n rs e tial, evidence• of suli& carryu\er e0den e of leakage into ortit of box, etc. 3� J�(.,'�/I•
aA1JAu CO. _ G
C fox
VA LU -!. S
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 8/15/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: (03 9 1RO!a ' W."Q4—
Owner: Hc, To41��� C)' z-
Date of Inspection: vv
p ttic)`�,a�r0
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.
leaching trenches, number,length:
leaching fields, number, dimensions:
overflow cesspool, number:
Comments: (nat coed' i i osoi
f l, signs of hydraulic slur level of nding, condition of vegetation,etc.)
C0 �C ,
CESSPOOLS:
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of grounckatef:
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: U-10V\e
(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 8/15/95) B
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
/` �
SYSTEM INFORMATION (continued)
Property Address: 10 Np��
Owner: Q t e \ l
Date of Inspection:
to--3s ,a
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
V
&40
A-Ao a = BO'S `' A-
A /4 ST 3 = 3Q,( r�
A 'TV -px;Ac Z-3q
5-V bao?,
DEPTH TO GROUNDWATER + ,
Depth to groundwater: L/ feet
method of determination or approximation:
(revised 8/15/95) 9
WELL DATABASE
e
ADDRESS:
AGE OF WELL: WELL DRILLER:
WELL PERMIT r: WELL LOCATION:
..._..WELL PERMIT DATE: � DEPTH OF WELL:
TYPE OF WELL: ,DRIL� b. UG C. OWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: HIGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTAMINANTS: Y N
WELL DATABASE
ADDRESS: 6
AGE OF WELL: WELL DRILLER
WELL PERMIT : WELL LOCAZON:
WELL PERMIT DATE: DSP H OF WELL:
TYPE OF WELL: a.. DRILLED� bDUG c. UNKNOWN
TYPE OF WATER BEARING ROCK:
WATER ANALYSIS DATE: HIGH MANGANESE: Y N
HIGH IRON: Y N OTHER CONTAMINANTS: Y N
JA ls)
107 Fo st �� FORM 4- SYSTEM PITi11PL\G RECORD
Middleton, A 949 QF.P'
(508) 7 -2 72 S�Q����v��E
cop Commonwealth of Massachusetts
Massachusetts
System Pumping Record
�stem �Vner
f ystem ocatton
f
Date of Pumping:
Quantity Pumped: gallons
Cesspool: No ❑ Yes ❑ Septic Tank: No ❑
Yes
r
System Pumped by:
License 4: .:
Contents transferred to: ��
Date
Inspector
• THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 0