HomeMy WebLinkAboutMiscellaneous - 66 JAY ROAD 4/30/2018 (3) �,_
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Commonwealth of Massachusetts
City/Town of
RECEIVED
System Pumping Record ED
Form 4
JUL "14 2014
DEP has provided this form for use by local Boards of Health. Other forms.!nqy,bsteed,ed,,but
information must be substantially the same as that provided here. Before using bjh 110.n ,,- �thGl your
local Board of Health to determine the form they use.The System PumpingRecor r�i ust b su m" to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left t front of hou Left/Right rear of house, Left/right side of house, Left/
Right side of building, Left/Right r int of building, Left/Right rear of building, Under deck
Address
(e
City/Town State Trp Code
2. System Owner.
Name
Address(if different from location)
CitylTown Statef� v de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2• Quantity Pumped: Gallons
3. Type of system yp y ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yep Id No If yes, was It cleaned? ❑ Yes ❑ No:
' 5. Condition of Sy tem:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. Loc&HauleV
tents were disposed:
GLowell Waste Water
SigDate
t5form4.doc-06/03 System Pumping Record•Page 1 of 7
COMMONWEALTH F MASSACHUSETTS
Z
EXECUTIVE OFF CE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT F ENVIRONMENTAL PROTECTION
A
�C
TITLE 5
OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 66 Jay Road
—North Andover
Owner's Name: Phillip Sullivan
Owner's Address:_66 Jay Road_
_North Andover,Ma 01845
Date of Inspection:12/11/2004
Name of Inspector: Neil J Bateson
Company Name: Bateson Enterprises Inc._
Mailing Address:_111 Argilla Road_
_Andover,Ma.01810_
Telephone Number:_(978)4754786
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
ils
c
Inspector's Signature: Date: _12/11/2004_
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or
DEP)within 30 days of completing this inspection.If the system is a shared system or has a design flow of 10,000
gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the
DEP.The original should be sent to the system owner and copies sent to the buyer,if applicable,and the approving
authority.
Notes and Comments:After connecting washer back into septic system for six months,camera outlet pipe to d-
box,normal level in d-box,septic system now passes Title 5 Inspection.
****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.
TOWN OF i
ECEeVED
' SYS M PUMPING RECORD
C MAY 3 12005
DATE: -; rp J TOWN OF NORTH AND
HEALTH DEPARTMENT
SYSTEM OWNER& ADD SS SYSTEM LOCATION
ii (example:left front of house)
0 V&
cJ
QUANTITY PUMPED : GAL ONS
DATE OF PUMPING: � '�,�"" � Q i O D[�
CESSPOOL: NO YES SEPTIC TANK: NO YES
I
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
Commonwealth of Massachusetts ! RECEI ED
City/Town of
System Pumping. Record APR 2 3 2009
Form 4 TOWN.OF NORTH ANDOVER
HEALTH DEPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important:
When filling out 1. System Location: Left front, left rear, left side of house i ht fron , right rear, rights of house.
forms on the
computer,use
only the tab key Address
to move your.
cursor-do not Cityfrown / State Zip Code
use the return
key. 2 System Owner:
Name
Address(if different from location)
Cityrrown Stat Zip Code
� � - f�Vo
Telephone Number
B. Pumping Record
l
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: Ll Cesspool(s) Septic Tank Tight Tank
Other(describe):
4. Effluent Tee Filter present? Ll Yes No If yes, was it cleaned? Yes No
5. Condition of System:
�aj V I
6. ,System Pumped By:
Neil Bateson F 5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
L.S.D Lowell Waste Water (�
tignallure of H u r Date
t5form4.doc•06/03' System Pumping Recons•Page 1 of 1
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:� —09---
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
t-al hoc
DATE OF PUMPING: "&—QUANTITY PUMPED_1C�9 GALLONS
CESSPOOL: NO YES SE TIC 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: �iirJ
COMMENTS:
CONTENTS TRANSFERRED TO: