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Miscellaneous - 70 LIBERTY STREET 4/30/2018 (3)
"'t'� ,C\ Commonwealth of Massachusetts u v City/Town of No Andover System Pumping Record Form 4 M 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 forms 1. System Location: on the computer, use only the tab 70 Liberty St key to move your Address cursor-do not NO andover MA. use the return key. City/Town State Zip Code 2. System Owner: Hamilton Name mnm Address(if different from location) City/Town �T State Zip Code Telephone Number B. Pumping Record XSq 1. Date of Pumping 2. Quantity Pumped: ate Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other(describe): --- 4. Effluent Tee Filter present? ❑ Yes L o If yes, was it cleaned? ❑ Yes�o 5. Condition of System.- 6. System Pumped By: Name Vehicle License Number Stewart's Septic Service �� G '� � ► Company 7. Location where contents were disposed: TcxNN Ste -reatment Plant, 20 So. Mill Bradford, Ma 01835 Signat tiler —�� Date Signature of Repeiving Facility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 �LN Commonwealth of Massachusetts 4 v City/Town of No.Andover 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 Pumpi vbwA Bd to the local Board of Health or other approving authority within 14 days fro the iii" 1 accordance with 310 CMR 15.351. A. Facility Information Important: TOWN OF NORTH ANDOVER When filling out 1. System Location: HEALTH DEPARTMENT forms on the computer,use ry (— tea: only the tab key Address to move your No.Andover Ma 01845 cursor-do not use the return City/Town State Zip Code key. 2. System O�n,ngC Name /Eh0" Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record ' 1. Date of Pumping Da 2. Quantity Pumped: Galleons 3. Type of system: ❑ Cesspool(s) 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 Syste 6. S to Pump d By: VAA Orb- Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 C,hnri 1 Signa re of H e Dat / / / ` Sig j��acility Date t5form4.doc•03/06 System Pumping Record•Page 1 of 1 Commonwealth of Massachusetts ��CI- a is VE-D Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessmen JUN 0 2014 70 liberty St TOWN OF NORTH ANDOVER Property Address Julie Hamilton Owner Ownpr's Name Information is North Andover INA 01845 6-2-2014 required for every _ _ �,_.._. page. Clty/Town State Zip Code fasts of Inspection Inspection results must be submitted on this form, Inspection forms may not be altered In any way. Please see completeness checklist at the end of the form. Important;When filling out forms Ar General Information on the computgr, use only the tab 1, Inspector; key to move your cursor-do not John DiVlnaenxa use the return •Wim'eafI ..,,......_. key. Narita of Inspector J and a Development qoT d Stewart's a tic Se rviee�, Andover�a tiC Company - r� p Y.Name 58 South Kimbell st Company Address Bradford ^ Y .�.w _�. Ma 01835 Citi/Town State Zip Code 975-372-7471 s113386 'telephone Number License Number Br Certification I certify that I have personally inspected the sewage disposal system at this address and than 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 ant a DBP approved system Inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: Lasses (D Conditionally Passes ( Fails Needs Furthsr Evaluation by the local Approving Authority IV6.2-14 Imap ors signature Date T 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 DBP, The original should be sent to the system owner and copies sent to the buyer, If applicable, and the approving authority. ""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 some or different conditions 0 use. t5ins-3113 Tltle 9 Mal Inspeetlon€qrm:$ubau,faee Sewage Qlweegl$yatsm--Page I of 1T Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Y 70 Liberty St Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01545 required for every ...�...,� .�....,.� 6-2-2014 page. City/Town Stats Zip Code Date of Inspection B. Certification (cant.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Lasses: 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: ReRlaced d-box B) System Conditionally Lasses: 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. Check the box for"yes", "no"or"not determined" (Y, N, ND)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. P 9 [] Y E] N ] ND(Explain below): t5ins•$113 Title 5 official inspection Form:Subsurface S"aige Disposal Systam-Page 2 of 17 1 µORTq 6 12 A =r 9 • Town of North Andover ` '•�,,,,> HEALTH DEPARTMENT s SSC MUSt CHECK#: 1 �)I-j DATE: 14 LOCATION: 9 n I-I VT 14 o H/O NAME: CONTRACTOR NAME:�� JW 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 $ -12�Septic Disposal Works Construction(DWC) $� ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $ ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer 4 wj'%%C IHED Commonwealth of Massachusetts Title 5 Official Inspection Form MAY Z92014 Subsurface Sewage Disposal System Form -Not for Voluntary Assessments TOWN OF NORTH A U /ER HEALTH DEPART 1 70 Liberty street Property Address Julie Hamilton ` Owner Owner's Name 6 information is North Andover MA 01886 May 20,2014 17 required for every page. Cityrrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When A. General Information filling out forms on the computer, use only the tab 1. Inspector: key to move your cursor-do not John DiVincenzo use the return Name of Inspector key. Stewarts Septic Serive vt_my Company Name 58 South Kimball street Company Address Bradford MA 01835 Cityrrown State Zip Code 978-372-7471 5113386 Telephone Number License Number B. Certification 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: ❑ Passes ® Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority Ins ors 4ture--- Date i T4 a 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. ****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. t5ins•3113 Title 5 official Inspection Form-Subsudece Sewage Disposal System•Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name Information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page. Cityfrown B. Certification (cont.) Inspection Summary: Check A,B,C,D or E 1 always complete all of Section D A) System Passes: ❑ 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. Check the box for"yes", "no"or"not determined"(Y, N, ND)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. ❑ Y ❑ N ❑ ND (Explain below): Wns•3113 Title 5 Offrcial Inspection Form:SubsuAaoe Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form -' Subsurface Sewage Disposal System Form Not for Voluntary Assessments Y 70 liberty street -.- Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page. Cityrrown B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes(cont.): ❑ 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 ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ® distribution box is leveled or replaced ® Y ❑ N ❑ ND(Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): 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(1)(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 a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetiand or a salt marsh t5ins•3113 Title 5 Official Inspection Forth:Subsudeoe Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every City/Town State Zip Code Date of Inspection page. B. Certification (cont.) Z. 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: [3The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supely or tributaryto 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 fecal coliform bacteria indicates absent 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: D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El ® 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 Y2 day flow Title 5 official inspectton Form'Suosexface Sewage Disposal System•Page 4 of 17 i5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form •Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every City(fown State Zip Code Date of Inspection page. B. Certification (cont.) } Yes No ❑ ® 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 SAS, cesspool or privy is below high ground water elevation. ® ® Any portion of 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 1 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. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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. For large systems,you must indicate either"yes"or"no"to each of the following, in addition to the questions in Section D. 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 It 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. Title 5 ow4at inspedw Form-Subsurface Sewage Disposal System•Page 5 of 17 t51ns•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every Cityrrown State Zip Code Date of Inspection page. C. Checklist Check if the following have been done. You must indicate"yes"or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of ❑ this inspection? ® ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ 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? ® 11 information the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS) on the site has been determined based on: ® 0 Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: 4 Number of bedrooms(design): 4 Number of bedrooms(actual): 4 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 600 GPD Tnite 5 otricial inspection Form;Subsurface Sewage Disposal System•Page 6 of 17 15ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page. Cityrrown D. System information Description: 4 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system?(Include laundry system inspection ❑ Yes No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Sump pump? ❑ Yes 0 No Occupied Last date of occupancy: Date Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seatslpersons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•3113 Tate 6 Official Inspection form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Last pump 12-13-12 Source of information: Was system pumped as part of the inspection? ® Yes ❑ No 1500 If yes, volume pumped: gallons How was quantity pumped determined? Site guuage on truck Reason for pumping: Inspect tank Type of System: ® 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) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Title 5 Official Inspection Form:Subsurface sewage Disposal system-Pape S of 17 l5ins-3113 Commonwealth of Massachusetts E-- Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments " 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page. City[Town D. System Information (cont.) Approximate age of all components, date installed (if known)and source of information: 29 Years Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): 20" Depth below grade: feet Material of construction: ®cast iron ❑40 PVC ❑other(explain): Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): Septic Tank(locate on site plan): 1001 Depth below grade: feet Material of construction: ® concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No Dimensions: Sludge depth: t5ins•3113 Title 5 official inspection Form:Suosurface Sewage Disposal system•Page 9 of 17 Commonwealth of Massachusetts - - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form- Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page, Cityfrown D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 28" 0 Scum thickness 6.. Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 17"' Tape measure&Sludge judge How were dimensions determined? Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc.): Both baffles in godd shape, no leakage Liquid levels good. Grease Trap(locate on site plan): Depth below grade: feet 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: Date i5ins•3113 Title 5 Official Inspection Form.Sub9ulface Sewage Disposal system-Page 10 of 17 Commonwealth of Massachusetts Title a Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page Cityrrown D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: -- Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 t5ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form -- Subsurface Sewage Disposal System Form Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owners Name information is North Andover MA 01886 20,2014 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): 0 Depth of liquid level above outlet invert 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.): Box detereated around outlet inverts. Sand entering box equal dist. Some solids carryover leakage into box. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *if pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS)(locate on site plan, excavation not required): If SAS not located, explain why: ritte 5 official Inspection form:Subsurface Sewage Disposal System•Page 12 of W 15ins•3113 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments x 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 2Q 2014 required for every State Zip Code Date of Inspection page. City/Town D. System Information (cont.) Type: ❑ leaching pits number. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ® leaching fields number,dimensions: 1-24X45 ❑ 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.): No hydraulic failure, no ding, no damp soils. - Cesspools (cesspool must be pumped as part of inspection) (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 ❑ Yes ❑ No Title 5 official Inspection Form.Subsurface Sewage Disposal System•Page 13 of 17 Gins•3113 Commonwealth of Massachusetts _ Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every City/Town State Zip Code Date of Inspection page. D. System Information (cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (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.): Title 5 Official Inspection Form:Subsurfece Sewage Disposal System•Page 14 of 17 t5lns•3/13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page City/Town D. System information (cont.) Sketch Of Sewage Disposal System: Provide a view 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. Check one of the boxes below: ❑ hand-sketch in the area below ® drawing attached separately Title 5 Official Inspection Form:Subsurface Sewage oisposai system•Page 15 of 17 Gins•3t13 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every State Zip Code Date of Inspection page City/Town D. System Information (cont.) Site Exam: ® Check Slope ❑ Surface water ® Check cellar ❑ Shallow wells 8'Tpl 4'Tp2 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: ® Obtained from system design plans on record If checked, date of design plan reviewed: 11/12/85Date ❑ Observed site(abutting propertylobservation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Pulled files ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: Taken from plans drawn 11/12/85 water at 4'. Elevation 109 bottom of bed at Elevation 113 4'water se eration. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form o Subsurface Sewage Disposal System Form-Not for Voluntary Assessments r 70 Liberty street Property Address Julie Hamilton Owner Owner's Name information is North Andover MA 01886 May 20,2014 required for every CityfTown State Zip Code Date of Inspection page. E. Report Completeness Checklist ® Inspection Summary:A, B, C, D, or E checked ® inspection Summary D (System Failure Criteria Applicable to All Systems) completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 t5rn s•3113 612 MOK71 • 0`"'.0 .� Town of North Andover HEALTH DEPARTMENT �ss.+caus°< CHECK#: DATE:,st�Q 14 J LOCATION: V�Pf+% I) H/O NAME: CONTRACTOR NAME: _ TyR,e 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 $ IJ Tobacco $ ❑ Tras0olid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic-Soil Testing $ ❑ Septic-Design Approval *Septic Disposal Works Construction(DWC) ❑ Septic Disposal Works Installers(DWI) $ ❑ Title 5 Inspector $ Title 5 Report $� ❑ Other:(Indicate) $ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer iANI A" CIA /i/o 1 ILE in ✓i O � 4 V S1L35�� Lo � . L r aGa' 't � �ioa 5•F� ,t3E17 -� �'f 42 lSaa CxA/� S�f'f'tC i�.5�/l� { t LrsaW6.�itC.sawttslR�.�qi'qY:iJFrnwz�.ar,L:.ulae+'w.SWVcr..:..u'usl.Y+GYM.Y�«:.w.Rsh`.'stt�q�K�'A"i.:�an,$itict2G+,rbM Commonwealth of Massachusetts _ City/Town of North Andover 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 within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important:When filling out forms 1. System Location: .. ) on the computer, f" use only the tab key to move your Address cursor-do not North Andover Ma 01886 use the return CityrFown State Zip Code key. 2. System Owner: Name revs Address(if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record Ic 1. Date of Pumping 2. Quantity Pumped: Gallons p g Date 3. Type of system: ❑ Cesspool(s)'1-2''�eptic 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. stem Pum d�By: am Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: LSignature s Pre-treatmen Plant, 20 So. Mill Bradford, Ma 01835 of Hauler Date R_ - o eceivwng Facility Date t5form4.doc•03!06 System Pumping Record•Page 1 of 1 0 . S�gJIVED anti „ PUBLIC HEALTH DEPARTMENT Town of North Andover Community Development Division CERTIFICATE OF COMPLIANCE As of: 6/2/2014 This is to certify that the individual subsurface disposal system received a SATISFACTORY INSPECTION of the: Complete Repair of D-Box By: John DiVincenzo At: 7070 LibertyStreet Map 090.B Lot 0053 North Andover, MA 01845 Th�e Issuance of this�ee ca shall not be construed as a guarantee that the system will function satisfactorily. Michele Grant Public Health Agent 1600 Osgood Street,North Andover,Massachusetts 01845 Phone 918.688.9540 Fax 918.688.8416 Web www.townofnorthandover.com � 5�'�� res, • • North Andover Health Department (ommunity Development Division ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS: 70 Liberty St. MAP: 090.B LOT: 0053 INSTALLER: John DiVincenzo DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: D-Box 6/2/14 DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPECTION: SITE CONDITIONS ❑ Contractor reports any changes to design plan ❑ Existing septic tank properly abandoned ❑ Internal plumbing all to one building sewer ❑ Topography not appreciably altered Comments: SEPTIC TANK ❑ Building sewer in continuous grade, on compacted firm base ❑ Cleanouts per plan ❑ Bottom of tank hole has 6 stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading ❑ Monolithic tank construction ❑ Water tightness of tank has been achieved by visual testing ❑ Inlet tee installed, centered under access port ❑ Outlet tee installed, centered under access port (gas baffle/effluent filter) ❑ inch cover to within 6" of finish grade installed over one access port ❑ Hydraulic cement around inlet & outlet Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon Pump Chamber installed ❑ H-10 loading ❑ Monolithic tank construction ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ cover at final grade installed over pump access port ❑ Water tightness of tank has been achieved by testing ❑ Hydraulic cement around inlet & outlet Comments: CONTROL PANEL ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: basement ❑ Alarm signal located inside: basement Comments: DISTRIBUTION-BOX ❑/ Installed on stable stone base ❑ H-20 D-Box Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) ❑ Schedule 40 PVC Pipe Comments: S Commonwealth of Massachusetts Map-Block-Lot 090.B0053 BOARD OF HEALTH PermrtNo North Andover BHP-2014-0631 - ------------------ ---- P.I. FEE F.I. $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John-L. DiVincenzo to(Repair)an Individual Sewage Disposal System. at No 7-0-LIBERTY-STREET--------------b—&x as shown on the application for Disposal Works Construction Permit No. BHP-2014-063 Dat 2014 y Issued On: May-28-2014 BOARD OF HEALTH • > , Commonwealth of Massachusetts Map-Block-Lot • 090.B0053 BOARD OF HEALTH ----------------------- Permit No North Andover BHP-2014-0631 ----------------------- FEE $125.00 ----------------------- DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted John L. DiVincenzo --------------------------------------------------------------------------------------------------------- to(Repair)an Individual Sewage Disposal System. at No 70 LIBERTY STREET �- �Q ---------------------------------------------- -------- - -------------------------------------------------------------------------------------- as shown on the application for Disposal Works Construction Permit No. BHP-20147063 Dated May 28,2014 ------------------ Issued On:May-28-2014 BOARD OF' ALTH . NOR7H Application for Septic Disposal System IZ 3:•`' DAY'S 'Construction Permit - TOWN OF TODATE ORTH ANDOVER, MA 01845 $125.00- Fom on ull art -..� SACHUSt1 Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer,use ❑ pair or replace an existing on-site sewage disposal system* only the tab key to move your Repair or replace an existing system component—What?. ° cursor-do not use the return key. A. Facility Information VQ Address��t# City/Town )V-d A# RECEIVED I 2.-*TYPE OF SEPTIC SYSTEM*: MAY Z 8 2014 El Pump ravity (choose one) ***If pump system,attach copy of electrical permit to applicatio '"I"HEALTH DEPARTMENTOWN OF NORTH ANDOVER Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser(Gravel-Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D-Box)(Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D-Box Present)S.A.S. 2. Owner Information Name ?d � 1 Address(if different from above) City/Town State Zip Code 7/_17,5T 975-- Telephone Number 3. Installer Information M. 1�6✓ IArccA.,7.a �✓"�"��vur j'c nz'� ,Svrvc� Name Name of Company�— mY Address ,����`t ` fYl� />1 8'342ity/Town State Zip Code ?2K a� ��4�7/ /V 51 Telephone Number(Cell Phone#if possible please) 4. Designer Information Name Name of Company Address City/Town State Zip Code Telephone Number(Best#to Reach) Application for Disposal System Construction Permit•Page 1 of 2 •! °f"OR "''1 Application for Septic Disposal System •°r 3�•`?+� ��s'p°c ° Construction Permit - TOWN OF TODAY'S DATE "• °' • �c'# ORTH ANDOVER MA 01845 $250.00-Full Repair �;��••.. $125.00-Component SSAClN1`'� PAGE 2 OF 2 A. Facility Information continued.... 5. Type of Building: esidential Dwelling or❑Commercial B. Agreement The undersigned agrees to ensure the construction and maintenance of the afore-described on-site sewage disposal system in accordance with the provisions of Title 5 of the Environmental Code,as well as the Local Subsurface Disposal Regulations for the Town of No Andove , nd not to place the system in operation until a Certificate of Compliance has be su d his oard of Health. Ne Date Application Approved By: (Board of Health Representative) Name Date Application Disapproved for the following reasons: For Office Use Only: 1. Fee Attached? Yes No 2. Project Manager Obligation Form Attached? Yes No 3. Pump Svstem? If so,Attach copy of Electzical Permit Yes No 4. Foundation As-Built?(new construction ronly): Yes No (Same scale as approved plan) 5. Floor Plans?(new construction only): Yes No Application for Disposal System Construction Permit•Page 2 of 2 i �"""'.• - -� -� +rNaeanWaa�xircw� - ...w l E &&D ' CIA l oig �''D PP GG F ,n,,,,figN�C llS•3s _ � c � 0 � x s a 133o• h • d• f �JDD S�F� l3E0 . t t 4 j i t d 5 STEVENS WATER ANALYSIS 38 MONTVALE AVENUE STONEHAM, MASS. 02180 Tel.(Stoneham)617.438.6114 Tel.(Salem,N.H.)603.893.3106 Interpretation of Test Results TOTAL COLIFORM The coliform test is used to determine the possible presence of septage pollution and pathogenic organisms in water. The U.S. Public Health Service has established that the coliform concentration should not exceed 0 per 100 milli- liters in public water supplies. An absence of coliform bacteria eliminates the possibility that septage pollution and pathogenic organisms are present in water. HARDNESS Hard waters are generally considered to be those waters that require considerable amounts of soap to produce a foam or lather and that also produce scale in hot water pipes, heaters and boilers. Specifically, hardness is a measure- ment of the calcium and magnesium concentration in water. These hardness minerals are responsible for ring and sediment buildup in bathtubs and sink bowls and many other domestic problems. From an economic standpoint, hard water can increase water heating costs due to the scale build up in boilers and also increase detergent con- sumption. Waters are commonly classified in terms of the degree of hardness as follows: 0-75 mg/l Soft 75-100 mg/1 Moderately hard 150-300 mg/l Hard 300 up mg/l Very hard pH Water with a pH of less than 7.0 is considered acidic. Water with a pH above 7.0 is considered alkaline or basic. A pH of 6.0 to 6.6 is moderately acid and may eventually corrode plumbing fixtures and water using appliances. A pH of 4.0 to 5.9 is considered very acidic and corrosion could be even more extensive. CHLORIDES Chlorides in reasonable concentration are not harmful to humans. However, they can give a salty taste to water which is objectionable to many people. For this reason the U.S. Public Health Service recommends that chlorides be limited to 250 mg/1 in supplies intended for public use. Salting of nearby highways is often the cause of high chloride concentrations in water supplies. IRON AND MANGANESE Iron and Manganese can cause problems with staining during laundering operations, impart objectionable stains to plumbing fixtures, and cause difficulties in distribution systems by supporting growth of iron bacteria. Such waters when exposed to the air become turbid and highly unacceptable from the aesthetic viewpoint. Iron imparts a taste to water which is detectable at very low concentrations and can be very objectionable at higher concentrations. Iron can also change the taste and color of beverages and food. For these reasons the U.S. Public Health Service Standards recommend that public water supplies should not contain more than 0.3 mg it of iron or 0.05 mg/1 of manganese. SODIUM Sodium in high concentrations can promote hypertension or high blood pressure in humans. Some individuals are more susceptible to the effects of sodium than others. Th-* U.S. Public Health Service recommends that sodium be limited to 20 milligrams per liter in public water supplies. Note: ml = milliliters NITRATE STANDARD: 10 mg/L mg/L = milligrams per liter ARSENIC STANDARD : 50 ppb LEAD STANDARD: 0.05 mg/L 4 NORTH ? OFFICES OF: 0 ° Town of 120 Main Street °� • North Ando\'er, APPEALS •a�.;.�.;_: NORTH ANDOVER vtassachusetts 0 1845 BUILDING CONSERVATION ,QS ""sit DIVISION OF (61 7)685.4775 I-IEAl-l'H PLANNING PLANNING & COMMUNITY DEVELOPMENT KAREN 1-I.P. NELSON, DIRECTOR April 8 1987 Nancy Sullivan Conservation Administrator re- Lot 4 Liberty St. I have not received the March 11 1987 revised plan you mentioned. The old plans I have seem satisfactory. No permit has been issued yet for this Lot and I specified not to issue anything until I review the revision. Thank you for bringing this to my attention. Sincerely _ Inspector Board Healthier mgIgc f t TOWN OF NORTH ANDOVER, MASSACHUSETTS OFFICE OF CONSERVATION COMMISSION f ,►ORTH 1 TELEPHONE 683-7105 9SSACHUS' M E M O R A N D U M April 7, 1987 TO: Board of Health FROM: Nancy J. Sullivan, Conservation Administrator Re: Lot 4 Liberty Street - DEQE #242-344 Gentlemen: At our meeting held April 1, 1987, the Conservation Commission considered a request for a modificaiton to an existing Order of Conditions for the above referenced lots. During the review process, it was brought to the attention of the Commission that the location of the septic systemm�ay) be within 100 feet of a wetland. Please refer to revise plans titled "Site Plan of Land in North Andover, MA,"prepared for Douglas Hamilton by C.W. Garvey Co. , Inc. dated March 11 1987 - Scale 1" =40' The Commission would like this letter to serve as notification of this situation. c: Planning NJS/mlb DWE FHq No. 24 400 (To be provided by DEOE) -- North Andover ' Commonwealth City/To wn _ - of Massachusetts - Applicant Douglas Hamilton Lot. 4 - Liberty Street Order of Conditions Massachusetts Wetlands Protection Act G.L. c. 131,.§40.• and under the Town of North Andover Bylaw, Chapter 3.5 A & B North Andover Conservation Commission From u a RPnub. ic�e3tPla i mant To Do gl s Hamilton — f roe owner) Na neo property Applicant) ( P P (Name of App ) 42 Colburn Road 100 Village Road Reading, MA 01867 Danvers, MA 01923 ;+ Address Address This Order is issued and delivered as follows: /`— —O i�-�•I applicant or representative on J (date) by hand delivery to app P , p by certified mail,return receipt requested on (date) This project is located at Lot 4 Liberty .Street - North Andover The property is recorded at the,Registry of Middlesex N. Book 2013 Page 227 Certificate(if registered) The Notice of Intent for this project was filed on Narch 24 i 9Fi7 ° , (date) The public hearing was closed on April 1, 1987 (date) Findings i The North Andover Conservation Commission has reviewed the above-referenced Notice of Intent and plans and has held a public'hearing on the project. Based or 'the'information available to the NACC at this time,the NACC has determined that the fbllowin9 Interests In accordance with si the area on which the proposed done is nificant'l, work is to be o g , s® forth in there ulation$for each Avea Subject to Protection Under the t 8 , Presumptions of Significance the p , as appropriate): . . , Act(check • • Ed/'Public water supply Storm damage prevention (la Private water supply Prevention of pollution' Ground water supply O• Land containing shellfish Flood control Fisheries BOARD Of HEALTH No-Andover, 'ass,, r w SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT APPROPED - DAB'S_______ DISAPPROVED DATE Z 1-�j Provid6d: Reasons: E'5 5 Title V FAIL OK Reg 2.5 The submitted plan must show as a minimum: a) the lot to be served-area,dimensions lot #� abutters b obsk location and retion and sults percolation on testson -distanceeto ties to c red leaching area d design calculations & calculations shoving required (e) location and dimensions of system-including reserve area f) 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 sewage disposal system or disclaimer (i) location any drainage easementsBoard I0' of sewage disposal system or disclaimer-Planning W known sources of water supply within 2001 of sewage disposal e system or disclaimer (k) location off any to serve lot-1001 from leaching facilitl . � ppropp osed well (1) location of water lines on property-10' from leaching facility (m) location of benchmark , (n) driveways (o garbage disposals (p) no PVC to be used in construction tic tank (q) profile of system-elevations of basement, plumb, pipe.. s eP distribution box inlets and outlets, distribution field piping and Other elevations 1(r) maximum ground water elevation in area sewage disposal system (s) plan mast be prepared by a Professional Engineer aplans professional authorized by law to prep such. Beg 6 S tic Tanks (a) capac t es-,50% of flow, water table, tees, depth of tees, access, pumping (b) cleanout (c) 10+ from cellar wall or inground swimming pool (d) 251 from subsurface drains Reg 10.2 Distribution Boxes (a) s pe greater than 0.08 w Reg 10.4 b) -sip Subsurface DesignCheek List Page 2 FILL OK Leaching Pits Leaching pits are preferred where the installation is possible Reg 11.2 a) calculations of leaching area-minimum 500 eq ft 11.4 b) spacing 11.10 c surface drainage 2% ?1.n d) cover material e) ilxvx4" splash pad f) tee at elbow g) no bends in pipe from d-box to pipe Leachin Fields Reg 15.1 a no greater than 20 minutes/inch b area-minimum 900 sq ft 15.4 c construction of field 15.8 d) surface drainage 2 % 3.7 e) 201 from cellar wall or inground swimming pool Leachin Teenches Reg 14.1 a) calculauone -leaching area-min 500 eq ft 14.3 b) spacing-4 ft min 6 ft with reserve between 14.4 c) dimensions 14.6 d) construction 14.7 e) stone 14.10 f) surface drainage 2% Downhill Slope a) slope y x = kto be shows) b) y/x Z 150 - (to be shown) EMS Reg 9.1 a) approval 9.6 _,Pb) stand-by power a w t, i w a a P-URD ofNF4L I i-1 LOT 57 NOJ�Tfj 4&)POVE)- M,4, , it (�?Aso'PLY wE� � 7 D TaVAJ AP RN eD Q IiE5 D Na ss I D 56HIC Sy STF,_AA PES�J ,SPP ovt"D DArt� S f i-�7 APRzovIIJ6 Aurhol?iTy -` COA)PiTlW5:: USS hFw © ��W I 5 .��q�o i'r.�l or� sys. e4AJ I"id PPRovED Oq T E P,ul ti � D. ScPt c SYSTEM 1 J STA ULAT►oAJ eX4V4T(OV J )NSP6:6T10ti D/JrC -�z-�7 E1 RASS P4iL- N�s SINAL IV 5pFGr1oA) ApP130VEP Q/3TC o��11��7 i4PFiDvING AUrHo/?aY DISAPMOV6D DArC FwA(. APPRpvat_ APPRO11W6 4v i ingj+ c'� . Page 3 ORDER OF CONDITIONS Lot 4 '- Liberty Street uDEQE #242-400 12. The work shall conform to the following plans and additional conditions: a. Notice of Intent of Douglas Hamilton dated 3/29/87. b. Site Plan of Land in North Andover for Douglas Hamilton dated 3/11/87 by C.W. .Garvey Co. , Inc. ,. 36 West Street, Whitman, MA c. Proposed Retaining Wall for Lot 4 Liberty Street, North Andover, MA prepared by Peter F. Dimeo, R.A. , dated 3/20/87. , d. . Drainage Calculations for Douglas Hamiling Lot 4 j Liberty Street, North Andover, MA by C.W.Garvey, , Whitman, MA dated 3/23/87. Hamilton re: proposed e. Letter to NACC from Douglasp p construction sequence dated 3/20/87.. 13. In advance of any work on this project the applicant shall notify the NACC and at the request of the NACC, shall arrange an on-site conference among the NACC, the contractor and the applicant to ensure that all of the Conditions of this Order are understood. This Order also shall be made a part of the contractor's written contract. 14. The applicant, or its successors, shall notify the NACC in writing, of the identity of the on-site construction supervisor hired to coordinate construction .during the work on the site and to ensure compliance with this Order. 15. Commencing with the issuance of this Order, and continuing through the existence of same, the applicant shall submit to the NACC a written progress report every sixty (60) days detailing what work has been done in or near resource areas. 16. Prior to any construction on the site, a filter fabric fence, (type of which shall be approved by the NACC prior to installation,) or a double row of staked hay bales shall be placed between all construction areas and wetland areas. This barrier shall be in- spected and approved by the NACC prior Ko Start of any construction. This 'row of filter fabric or hay bales shall remain intact until all disturbed areas have been mulched, seeded, and stabilized to prevent erosion. I j ?:.,.. .. ° ' Town of OFFICES 01=: o�°, 12O Main Scrcct APPEALS o ..,: aNORTH ANDOVER North Andover, IiL 111 LDING Massachusetts�)1845 C.ONSFRVA I ION SSCNV9fI)IVEMON OF (G 1 i)G85-4775 HEALTH PLANNING PLANNING & COMMUNITY DEVELOPMENT KARLN H.P. NELSON, DIRECTOR May 12 1987 Nancy Sullivan Conservation Admistrator a re- Lot 4 Liberty St. Attached is a copy of a revised plan dated May 6 1987. On May 11 1987 I verified the wetland offset on the site and it appears that the leach area as shown is at least 100 feet away. My notes are , included on the plan. Sincerely Sanitarian BoarrH6-altft- cc Douglas Hamilton 42 Colburn Rd. Reading Mass. 01867 Ii r I . . . . o .,«:4ry�,�+wy{t •;W?tii' t• t K:,'t:}i•r ., �,., J/.'{ r .. •. %via 4 • .e.�'i,�°r'•' .. :,'; . YY JJ 0 6 205 ' 'E'f)WN U�• rYUK'I'r� , n'lh VA i'{ / GZ s Y 9 TB t,•1 P U M P I N() �F8 DEPARTMENT R . „( ...., sYareM ADOR2ss TI TY �•� --.,_..,...... . �lPUMf'�C v P'QOL; NQ N� rvxtr OF nAyl ! aC)4p GOt O�'t'iUN rVLL f*U L'C)Y h x Rom.: ..,.... U rlYYt.8 J 1N eXPLAIN t°UMM�NTs. ! f 1 LABORATORY ANALYSIS a e e Stevens Water Analysis 38 Montvale Avenue • Stoneham, MA 02180 • Mass. (617) 438-6114 • Salem, N.H. (603) 893-3106 LABORATORY NUMBER: 167298 SAMPLE DATE: 6/16/87 SUBMITTED BY: Wilmington Pump 639 Woburn Street Wilmington, MA 01887 SAMPLE SOURCE: Artesian well/collected from pump Lot #4- No. Liberty Street, No. Andover_ , MA ANALYSIS: Accord-- ng to tandpard Methods of Water and Wastewater Anal y sis l f;-th Ed . - - Total Coliform . . . . . . . . . 0 per 100 ml Chlorides . . . . . . . . . . . . 7 mg/L pH _ . . . . . . . . . . . 6.9 Hardness . . . . . . . . . . . . 50 mg/L Manganese . . . . . . . . . . . . 0.04 mg/L Sodium . . . . . . . . . . . . . 7.3 mg/L . . . . . . . . . . . . 0.99 m /L Iron g Nitrate . . . . . . . . . . . . . less than 0.10 mg/L Nitrite . . . . . . . . . . . . . less than 0.10 mg/L COI1ZIENT : The results of these analyses meet the required federal and state standardE for drinking water. However, the iron con- centration exceeds the recommended standard. Although iron is not harmful to your health, it can affect the taste, color_ and odor of your water. Iron is frequently found at elevated levels in new wells; however, it is likely that the concentration will decrease when the well is put into regular use. Water quality can vary significantly from time to time due to various local conditions. It is advisable to have your water tested in approximately six to twelve months to determine any change in water quality. 011m , ll A Ca- ist icro 1 ist COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS > DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 v V� TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 70 b ber-V5t Nei Atiod�er Owner's Name: Owner's Address: Date of Inspection: Name of Inspector: (please print) -,h r'1 b%y 1 n r c n� k s Company Name: Sj'uA r t 15 5 - iC Off Mailing Address: 47 !3G I Iro4d Sr ' Telephone Number: 9 8 2227 7 7 3 / y 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: Passes Conditionally Passes Njjj he raluation by the Local Approving Authority FInspector's Signature: Date: The system inspector shall mit a co of this inspection repo the Approving Authority(Board of Health or Y P PY P DEP)within 30 days of co pleting 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 ****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. Title 5 Inspection Form 6/15/2000 page I Page 2 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: '76 b b-e/4� 5f —&0 Lhib Owner: Pam l I P4 Date of Inspection: Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: __Zl 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 exiif'Any failure criteria not evaluated are indicated below.,, � I 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. O u " w t determined Y N ND in the for the followin statements.If not determined lease Answer yes,no or no ( ) a p 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: ' OWervation`ofsewd&bd kup 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: 2 Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: "7/5 L i b/- +q 5' 0'a Owner: Date of Inspection: 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 ii 'accordance with 310&R 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 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 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 1*T#►is Wstei passes if thewell water,a4alygis,performed at a IEP 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: 3 Page 4 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: "70 J.l {-er4_0 AM Ar►Q1kzr_ Owner: Date of Inspection: - D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes N oVackup of sewage into facility or system-cornponentjdue to•overloaded or clogged SAS or cesspool Discharge or ponding of effluent to the surface of thl ground or surface waters due to'an overloaded or logged 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 ''/z day flow _�equired pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).Number �,,of times pumped _ y portion of the SAS,cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface pater supply. Any portion of a cesspool or privy is within a Zone 1 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. [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.] U (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. 4, 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. 4 Page5of11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: A i h•F✓� NO APP4Wi"' Owner: A44en I / k Date of Inspection: Check if the following have been done.You must indicate"yes"or"no"as to each of the following: Pumping information'was provided by the owner,oG upant- ,or Board of HeaA 3 , /Were any of the system components pumped out in !!the previous two weeks? V _ Has the system received normal flows in the previous two week period? — Have large volumes of water been introduced to the system recently or as part of this inspection? Were as built plans of the system obtained and examined?(If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? Was the site inspected for signs of break out? Were all system components,excluding the SAS,located on site? 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? _V olo, Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The she'anid lo'catio' n of the Soil Absorption System(SAS)-on the site has been determined based on: Yes no Existing information.For example,a plan at the Board of Health. 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)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:_ 76 L.1 ,e v Iur k vo An o _(,- Owner: }{Am i Date of Inspection: 9-!SrG FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): Number of bedrooms(actual): DESIGN flow based on 310 C 15.203(for example: 110 gpd x#of bedrooms): Number of current residents: ' Does residence have a garbage grindet(yes br no)//Q ri S Is laundry on a separate sewage system(yes or no jM [if yeskeparate inspection required] Laundry system inspected(yes or no): Seasonal use: (yes or no)M Water meter readings,if available(last 2 years usage(gpd)): Sump pump(yes or no)ZV ' Last date of occupancy: 1 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sqft,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: Last date of occupancy/use: OTHER(describe): GENERAL INFORMATION Pumping Records Source of information: Was system pumped as part of the inspection(yes or no):VjfS If yes, volume pumped�allons--How as guars ty pumped dekrmined? a } Reason for pumping: /�(/ 7' ` TYPI6 OF SYSTEM 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) _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): App ro imate age of all components,d installed(if known)and source of information: v Were sewage odors detected when arriving at the site(yes or no):: 6 Page 7 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: L!b.,r`4. " oa r Owner: '-1 A M i--4 Date of Inspection: 9-5i�1 BUILDING SEWER(locate on site plan) Depth below grade: /46 �r Materials of construction, ast iron _40 PVC other(explain bistance from private water suplly well or stiction lie _ t Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK:_ locate on site plan) Depth below grade:�~ Material of construction: rete_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: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 6 , Distance from bottom of scum to bottom oLqutlet tee or baffle: r How were dimensions determined: Comments(on pumping recommendations, let and outlet tee or baffle condition,structural integrity,liquid levels as related to outlet ' vert,a iden of leakage,etc.): r.. Al ` GREASE TRAP:_(locate on site plan) ' 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.): 7 u " Page 8 of I 1 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: J6 61• Alo.-AvoJile I" Owner: 11nm Date of Inspection: G) C I TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: 1 ftcrete-i .metal 'fiberglass; J Polyethylene ther(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:— (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Q 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, tc.): , a Q '* a r r a&ter 0 PUMP CHAMBER: (locate on site plan) Pumps in working ot'der(yes or rp): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 ,• Page 9 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -70 /-1 b 6-Q 'fi Owner: tl) Date of Inspection: SOIL ABSORPTION SYSTEM(SAS): (locate on site plan,excavation not-required) If SAS not located explain why: Type leaching pits,number:_ leaching chambers,number: leaching galleries,number: 1 aching trenches,number,length: eaching fields,number,dimensions: 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.): o U c.c i v o dtJd l�v CESSPOOLS: (cesspool must be pumped as part of inspection)(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 groluadwater inflow yes or no): I rt A Comments(note condition of soil,signs of hydraulic failure,bevel of ponding,cbndition of vegetation,etc.): PRIVY: (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.): 9 • Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEMINFORMATION(continued) Property Address: d L( $r T. U Owner: kAatnull ;�P) Date of Inspection: — =r 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 wi in l0A feet.,Locate where public wai#supply enters thikuilding. U ao� 10 Page 11 of 11 + OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: -7f_ � - Lt �� �� Owner: 1 rim I Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells - - Estimated depth to ground water feet i 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: 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 estaplished the high ground water elevation: + 1 1j 11 p 5 - a ¢1,X.x�d rIo !`t+ft +r t.Ir , +`t:. ✓. tr'. t }/�,�� //y , t tFrtkftf'r jk.r tf i i 71 >' 1' t 'n r ;'1 t. r 'I. WT• 3 1001 TOS OF NORTH ANDOVER SYSTEM PUMPING RECORD {l�-�+�,{i`��YiYIi�`4'4���j� �,i� ,.;• I �.. �,r�`�it 'r ,,. ; -22 L' a ' F t�_Imo, 1 t, :. I r rtr + 1 iK ti«�♦1t :S��t yi t Y�13>'I t.. ,a j i) C S � • SYSTEM OWNER&ADDRESS SYSTEM LOCATION ` r hA•frout of house) 5,,• ,.I ,./ ♦ i S ;r4WFX '.rtla'tf Ci`crt s t ,�„f .-•-�-I�� .�1� 1 i �- t �!. .. V. t <'AA �r. ri . (�/,/lKL/(✓ � if. ': s 5 r it+� j+r14 ! r ��'�i �t'�♦ ���?;' r;��ATE.OF'PUMPING; 'S v/ U ,F ANTITY PIMPED GALLONS 4�arr � �<<�. ; '; $POOL: NO .YES SEPTIC TANK: NO YES •YiTUitE OF..SERYIC . E. ROUTINE EMERGENCY . w •' tR`7 y !^rtfY�1 .�'�1';k`tf f�"! 1 w�'� it in l tl. ••i f �''M1 ^ `h" •�k�4iYri�`�arl:� ' �, lid' T�ONS: GOOD CONDITION 'FULL TO COVER Ctr f� r Y i ,� 4i , ,` HEAVY GREASE BAFFLES IN PLACE ` ROOTS r 1`' �' ' r LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED f SOT.IDS CARRYOVER t t (EXPLAIN) OTHER 'UMP�n ,• wK; frt b�,r,fi f*,,,h i. �;rk. 4 ,rn"`n•t t ti Af(y � �I { . is t�r .—�I C 1 WQ Nj itCp'y�- Ry.1'7 ri It^�i.l�,. + �• - k;,"+wT�"S�1�'�II '".;., T'„"..'T1/• � �/ �:t`. •, ��•� .lT tif�YJO:F•�1)�:;ltyrt t,�1 1 ./f,�c`•:.'�.; R y A �? ; 1V DOVER, MAS ' " •� � ,JfL C .,, ,+,. SACHU, ETTS; f� ! ..� S Vie. t: ..0 m `R c //017 a+ a O L (J 1 �d' �+ ��•s#�;1'�.flay �, t�� ,. ` '°t;4?c,' •n. fLo�1I�111 V' ,,j`y'r�%7�1`i•'G4)y 1'yC����Y rtyltii=,N;•:rl•;: .tt '1 1.1!,j 1%• •l�l�ttl•1'1'Tl't!'i.f+'r!.v,a,�r`C�•QS;,t.itl.�r..''�� �. •�,\1,••,(!'.,,.�,, �c•'•K 'h•;l..d,,,,ar,'.(w,.C(;i.'�;�;t,,.u,y.,..,(r'rr '''.r , .' �U}.._R , DEP,.hai rovlded ; P, thls,form for use by local Boards of Health�The System Pumping Recora mus: ba submlad to the.local'Board of Health or other approving authority, A;, Facility Informption :f;,,(Wp:►l�en(�_ Ing-out: .1.. System Location cunpu `. r. only the tab key .., Address - 5zo to move your:: . ', arsoc•do dot - Q. `use the'rettirn' :' :;: •CIty/Town • . •,. . State Y `. '; :. %ii•Irs ..r`i.' .. Zip Code ,6. �;i'�I' ';,.• "System Ow , val,'t'f ,• . `,�+ ;,''+,,,:•.,� ^!1;': :,;�r�.Name': ',r';�r ;': ., rr:i::,:. ,.,.�., 'Address 1I different from locatlon {' ( � . Cltyyll ovm i.'.'• ; State _�Z(,ye ode Telephone Number t := P,umplt�g .Reoord r' {�'�: ,. •'1•` i.:tyle , ' .i;i.k't;,,'.r�i(tarr:+7ii%l �i141i.f''rl ' ,•� 0t of Pumping 2, Quantity Pumped; Gallons ':Type Gf system;. ❑ . Cesspool($) Septic Tank :;:. ;,.'t:' ❑ Tight Tank '.IOther(descr1be);:- '"r !Effluent Tea Filter present?.❑ Yes o If yes, was It cleaned? ❑ Yesa'• v...':';,. `.., ,,.. ;app t.(r;:' tlon`of:Syst(]�m. r,;i:;• :;ei.; •..Y,., .•:h,'!:�:ift lt�!'YjY:,!•1•l�+;jay?E,.. bv�~i:,.K�`._'p�',' �"` _ �/ 1 _ ii�' •iii•,r:.. Yu:J,:b:�;h4�r;'1+'r' 1�' _ Pumped By;" -'i,• '7: � :•, %;'N jIre•:1't•�',i�a'•% a��'':+C' v, Vehl .;•', •, '•;''.,i,•�i; �;i,.��).w�Y'7•�14rf1 lfr'1�I "1 •.>✓a' a .�� 1ia N �';.•.,.: ,;�.•�.. clo Ucen�e umbor �i'j:x.11 r�-`l]`�;`,h r".r�.�;i�� .11fJ 41vr' �' •1 "? t: r I / •1•:� .1•�':�;•Y Y/'✓'/. ill•'!LS:.;., t I lye{,'�' ,'1,���l� /.Y�, V•'�1 i •:('i F�,;; s:7,:',.Lo�aflonvhere'contehts were:dl;3posed, '•J. 1,1,,.'s':�i•,1.x•.1 v.' Y. ':' ..i ' .; :s:• .:i, t,i,n�?'1,:.;,r.";1f a'.I,.L;:••; ,,;},�'�•L, 1"�:,,1,,�„ :I v •✓..{:_ `L ri.�• 'r"�li•��i...'1 1!',�'•+, Plr•1."l'4{ Yi:`yi}i ' :t'�i.. �:i l'�`•,'}'''•.,v S'• .� .•.,,, Pi •i .f•jf�C•,'4.'••���1 .�.:♦Iw,y.,'.4.i:''" •. , •SlQnatureofHaule(;iK Date ' htfPJ/utivw.meas,gov/dephvater/approvals/t5forms,htm#Inspect . , t5form4,doa!081Q3 ..; ' ' ;•• • System Pumping Recod Page e t of ED .. ... .. ..,.. ..... ............ .. 1`ZE'io! y i:. TOWN OF NORTH ANDOVE (� SY TEM PUMPINQ UCORI., NOV - 3 2004 UAIk OF NORTH ANDOVER TOWN HEATH DEPARTMENT SYSTEM OWNER dt ATME S SYSTEM LOCATION *41� AD• �'77'IG '4Axp DATE 4F PUMPTNU:�� QUANTITY PUMPED: L'lrSSPOOL: NQ__. YES ... .. Stlptic Tank: NO._...... YES NA ruRE OF SERVICE: R(UUTLNk:_... . . -Ml✓RUENC'Y 016SERVATIONS: GOOD CONDITIONFULL'TU COVER HEAVY GREASE BAFFLES IN PLACE. ROOTS _ LEACKRELD RUNBACK _.....__. BXCUSIVE SOLIDS __ FLOODED SOLID CAKRYOVER............OTHER EXPLAIN SY$Lom Puntpcd b7 .....S.J!C���- ....... . _ .. �r. vices rra. �-'UMMENTS CUN FEN I'S I'KAN3YERRED I'L) TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE NOV, /3, ,2166-3 - 2 SYSTEM OWNER 1&ADDRESS SYSTEM LOCATION #om) - 76 Li1)2rll �' N . Q"�' de ve�' Iva. DATE OF PUMPING I I i 3 QUANTITY PUMPED j 0 n CESSPOOL NO YES SEPTIC TANK NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION FULL TO COVER HEAVY GREASE BAFFLES IN LACE ROOTS LEACHFIELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY z J COMMENTS: CONTENTS TRANSFERRED TO Commonwealth of Massachusetts City/Town of NORTH ANDOVER MAS System Pumping Record ' Form 4 NOV 13 2006 DEP has provided this form for use by local Boards of Healt The System ecord mu, be submitted to the local Board of Health or other approvin �f gg "(api h A�U� q DEPARTMENT —i A. Facility information Important: When filling out 1. System Location: forms on the computer, use a only the tab key Address to move your ------ -- - cursor-do not ----- —__.___— __—_.--T.— _.�_ use the return City/Town —_. -- - ---- State key. Zip Code 2. System Owner: Name Address(if different from location) - - City/Town —_ _- __ --- - _ ------ State-------------- Zip C - - ._ --- _ s.4 a— - _ - Telephone Number - Z4. umping Record ate of Pumping �0 V _._ Date - 2. Quantity Pumped: ---•-_--__._._..._ Gallons pe of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank Other(describe):luent Tee Filter present? ❑ Yes o If yes, was it cleaned? Yes ❑ No ndition of System: 6. Sy em Pumped By: __— Name Vehicle License Number Company 7. Location where contents were disposed: t ature of Hau t -atehttp://www.mlass.gov/ p/water/ provals/t5forms.htm#inspect t5form4.doc-06/03 System Pumping Record•Page 1 of .C-\.. Commonwealth of Massachusetts RECEIVED Cityfrown of System Pumping Record JAN 101011 Form 4 TOWN OF NORTH ANDOVER iv HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms m--ay-5i-u-s-R, bute 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 XAMIt en fling out 1. System Loca 'on: nsonap to the .use v f the tab key 'Address nova your North Andover ma 01886 sor"do not City/rown state Zip Code the return ' '2: System Owner. A, Name Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 12 1 1. Date of Pumping 2. Quantity Pumped: I p g Date Gallons 3. Type of system: ❑ Cesspool(s) t[-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: nos-, 6. tem Pumped /'p l_"c Name Vehicle License Number Stewart Septic Service Company 7. Location where contents were disposed: Ste its treatment Plant 20 So. Mill St Bradford Ma 01835 Signature of Hauler Date Signature of Receiving Facility Date xmCdoc-03106 System Pumping Record•Page 1 of 1 , Commonwealth of Massachusetts RECEIV�D City/Town of North Andover FEB 0 5 Z013 Pumping System in Record Y M g TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT �M 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 forms 1. System Location: ` on the computer, use only the tab0 it V-)Pfy key to move your Address cursor-do not North Andover Ma 01845 use the return City/Town State Zip Code key. 2. System Owner: , U a Name relrm Address(if different from location) City/Town State Zip Code Telephone Number B. Pumping Record c, r \ 1. Date of Pumping 2. Quantity Pumped: 1^V Date Gallons 3. Type of system: ❑ Cesspool(s) [� 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: cd 6. S stem B Pumped : P Y 11� ame Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. 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