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HomeMy WebLinkAboutMiscellaneous - 707 JOHNSON STREET 4/30/2018_, _ � � - i N O � O � ' � O Q = � � z c�Qj5�'i m o m �� SEPTIC SYSTEM INSTALLATION IS THE INSTALLER LICENSED? TYPE OF CONSTRUCTION: YES NO NEW NEW CONSTRUCTION: CERTIFIED PLOT PLAN REVIEW YES '-O CONDITIONS OF APPROVAL YES NO (FROM FORM U) ISSUANCE OF DWC PERMIT E NO DWC PERMIT PAID?NO DWC PERMIT NO._ INSTALLER��(F, Qy6CQb BEGIN INSPECTION YE NO: EXCAVATION INSPECTION: NEEDED: PASSED ✓ BY CONSTRUCTION INSPECTION: NEEDED: AS BUILT PLAN SATISFACTORY: C YES: -) APPROVAL TO BACKFILL: DATE: FINAL GRADING APPROVAL: DATE FINAL CONSTRUCTION APPROVAL: BY ��DL BY .,-J---) DATE:, 9/G%G BY �JIJ t5fbrm4.doc• 06/03 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 RECEIVED SEP 16 2014 TOWN OF NUR I H 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 1. System Location: Left / Right front of house, Left / Right rear of house, Leftht sid;ec hour Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under c Address � •[�, �7 ��` w - � �� city/Town _ ( \�1)� State Zip Code 2. System Owner. Name' Address (if different from location) C4,1TOwn . State Zip Code Telephone Number 1 B. Pumping Record j 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system. ❑ Cesspool(s) ptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes o if yes, was it cleaned? ❑ Yes ❑ No, 5. ConditiMof stem: Q 6. System Pumped By: Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: fs i7l Lowell Waste Water SignAtufe qt Haul Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts _ City/Town of LMV�Oew§6:1 System Pumping RecordForm 4 RDEP has provided this formfor use by local Boards of Health. Other forminformation must be substantially the same as that provided here. Beforem, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / ht side of hour eft / Right side of building, Left / Right front of building, Left / Right rear of building, Under ec c Address / ,�--�s Cityfrown State Zip Code 2. System Owner. (`, Nc Name \ t5fbrm4.doc- 06/03 Address (f different from location) City/Town Statezic/'� �,-- •� Telephone Number �< B. Pumping Record 1. Date of Pumping 3. Type of system. ❑ ❑ Other (describe): Data 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition of stem: 0J&� Ik- �v 6. System Pumped By.- Neil y: Neil Bateson Name Bateson Enterprises Inc- Company ncCompany _ 7. Location where contents were disposed: F5821 Vehicle License Number System Pumping Record • Page 1 of 1 COVENANT IN REGARD TO SEPTIC SYSTEM We, the undersigned buyers of property at 707 Johnson St., North Andover, Massachusetts, affirm that we have been advised that the septic system to be installed on the property, in connection with Title V regulations, will have a capacity sufficient for a maximum of three bedrooms. We also understand that Title V regulations do not affect the number of bathrooms on the property. We have been advised and we understand that the rules and regulations of the Town of North Andover will not allow more than three bedrooms at this location unless more capacity is added to the septic system or the area is serviced by town sewer, but that the number of bathrooms at the location is not limited. We also affirm that we have been advised and understand that it is the responsibility of the installer of the septic system to provide a septic system conforming to Massachusetts Title V Regulations, that the installer will provide for erosion control and that the final raking and seeding of the septic system shall be the responsibility of the sellers. WITNESS OUR HANDS AND SEALS THIS DAY OF DECEMBER, 1996 Witness to All Andrew S. Wasserman, Buyer Stefanie J. Wasserman, Buyer COMMONWEALTH OF MASSACHUSETTS Then personally appeared the above-named Andrew S. Wasserman and Stefanie J. Wasserman and acknowledged the foregoing to be their free act and deed before me, ,Notary Public My Commission Expires: -'!nJa 9. Wafoustlwz c4ttoznzg o¢t Zacv 23 Main Street Andover, Massachusetts 01810 Telephone: (508) 475-7080 FAX: (508) 475-6070 December 4, 1996 Town of North Andover Title V Inspector To whom it may concern: Please be advised that the Covenant in Regard to Septic System, signed by the Buyers will be recorded at the Essex North Registry of Deeds at the time of closing. C�;Ir Lida T. Kalous 'an LTK / cmf N Oz � orin, IN v� Ed IQVJ -- /yam p�-�aa• O N °L Cn c z O U- O a t/) 7- d Q� Ln V) �O z _ Og.Q U cN eLw Ln 4C OLA.m x Cn QF J o CO0 , Z,- * Z.:2 Cie CO w0 qo > ac z O u, �'- > w � J ..i N N O yj °L c z O U- OC a 7- a- f— V) �O 0 U c, ,.• �� o c z a f— V) �O � ff Q �( w i l _ r e tvw`f � N M �. W Q v { Lf L /8366:a14 € i LaOW JO1NMOL r Tl --op ca 3 W sf, t II� WIN x r— N Q OL > Q� O w o Q- ULn Q z O0•Q Cie u� QC O h o W -CO off' �F- c ! z z.2 LLJ Cie CO C) W,o, Qth > ac Z �'- > O � LLJ J J J N. N x Q OL > U- O w Z Q- OQ x t -W- W a' f/ -=� /l azERS�a' I tal • " e cn Q Q� QC I O U w W I tal x e-- cn Q Q� QC O O U w Q QG Ln Z O u Q� uCAC O r-, O u- ao QF— COLO `Z ij O re) Z °` co o j.J Q Q lr) > OL z WJ> ~ w O V) J J N N x cn Q QC O U- w Z O� x Aa d I o �J i �.� x O O U- a Z O� U >-J- JV) -JJ(n J D QO F- 6-� N. y,, :i► N � Q 6f J Lw 0. T �0 F- F - F3 O U. Q CSC 2 • Z O��° w09 O r4 t--, p u- X m Q) Q _..J CD fes- Zr LV Q M og 00 �..� O Q In > oC Z �> w O J N N TOWN OF SYSTEM DATE: SYSTEM OWNER & ADDRESS Cliff X411) 11,11 1� RECEIVED MAY 2 5 2005 TOWN OF NORTH ANu�)VER HEALTH DEPARTMENT 'YSTEM LOCATION (example: left front of house) r i SIAL DATE OF PUMPING: _ QUANTITY PUMPED : GAL ONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D ✓ Lowell Waste l G' G -moi • O G C'6 M%�. NX Form No. 4 Town of North Andover, Massachusetts BOARD OF HEALTH Dacamhar 4 , 19 _9_5__. CERTIFICATE OF COMPLIANCE This is to certify that the Individual Soil Absorption Sewage Disposal System constructed ( ) or repaired ) by INSTALLER at si- has been installed in accordance with Board of Health Regulations as described in the Design Approval Site System Permit No. 871 dated Qrto 4 —4-, 19_ U The issuance of this certificate shall not be construed as a guarantee that the system will function satisfactorily. 0!%� OF HEALTFF-- NORTH ANDOVER BOARD OF HEALTH DESIGN REVIEW REPORT FEE: *0 PERMIT ## DATE RECEIVED 161314� APPLICANT f-1146 7-6 �/�/��A-) MAP PARCEL ADDRESS 7d7 JQf.14)WLOT #k ENG. (6 STREET 707 JOl;,W s4k--� ADDRESS �� /« y ��• r X/fai1 PLAN DATE 9 �a�/ REV . DAT CONDITIONS OF APPROVA APPROVED DISAPPROVED REASONS FOR DISAPPROVAL: /qZ6-;Ig AVO 7- 90 ,� T-0 � ��—mss �� � r - 1 14ORTN yep,+ O O L 40 �o# ,SS4CMUSEt Applicant u Site Location Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH g �l DISPOSAL WORKS CONSTRUCTION PERMIT Permission is hereby granted to Construct ( ) or Repair (,4"'an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD O -HEALTH Fee _L . D.W.C. No.—LL-7 APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT DATE: 11 Z 0 (4 CURRENT INSTALLER'S LICENSE# LOCATION: ZD 7 LICENSED INSTALLER: C SIGNATURE: TELEPHONE# or CHECK ONE: REPAIR. NEW CONSTRUCTION: IF NEW CONSTUCTION, PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attached? Yes V No Foundation As -Built? Yes No Approvalkz 61u� Date: STEVEN J. D'URSO Environmental Designs 22 Lilly Pond Road W. Boxford, MA 01921 (508) 352-9872 / : WE ARE SENDING YOU [LEVUEQ (11F MUSED"TUL DATE / a G JON NO. ZZAP ATTENTION IF RE ❑ lU N nr ain_"_a r. ,nnwg: ❑ W 7 ❑ As requested ❑ U - Attached❑ nder separate cover via � the following items: ❑ Shop drawings Prints ❑ Plans ❑ Samples ❑ Specifications ❑ Copy of letter ❑ Change order ❑ COPIES DATE NO. DESCRIPTION ❑ For your use ❑ W 7 ❑ As requested ❑ U - ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 THESE ARESMITTED as checked below: REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: If enclosures are not as noted. kindly notify us of once. For approval ❑ Approved as submitted ❑ For your use ❑ Approved as noted ❑ As requested ❑ Returned for corrections ❑ For review and comment ❑ ❑ FOR BIDS DUE 19 REMARKS ❑ Resubmit copies for approval ❑ Submit copies for distribution ❑ Return corrected prints ❑ PRINTS RETURNED AFTER LOAN TO US COPY TO SIGNED: If enclosures are not as noted. kindly notify us of once. � NORT►� A x w ,SSACMUSE�'A Town of North Andover, Massachusetts BOARD OF HEALTH o cl . A4 19 DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No. Site Location--) c) Reference Plans and Specs. ENGINEER C) , U CS O Form No. 2 Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. t Fee LrIo CHAIRMAN, BOARD OF HEALTH Site System Permit No. O_� ` WILLIAM J. SCOTT Director Town of North Andover OFFICE OF COMMUNITY DEVELOPMENT AND SERVICES 146 Main Street North Andover, Massachusetts 01845 October 15, 1996 Steve D'Urso 22 Lilly Pond Road Boxford, MA 01921 Re: 707 Johnson Street Dear Steve: This is to inform you that the proposed plans for the site referenced above have been disapproved for the following reasons: I . Reserve area not addressed. 2. Less than 900 square feet in field. 3. Not designed for 440 GPD minimum. 4: Less than 4 feet to groundwater. (variance requested) 5. Are trenches possible? If you have any questions, please do not hesitate to call the Board of Health Office at the number below. Sincerely, Sandra Starr, R.S., Health Administrator BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535 PLAN REVIEW CHECKLIST ADDRESS 7a Z ,/,Q #A)) , QIQ S 7- ENGINEER D /0�-9fO GENERAL / / / 3 COPIES �✓ STAMP ✓ LOCUS t/ NORTH ARROW SCALE CONTOURS PROFILE SECTION BENCHMARK SOIL & PERCS ELEVATIONS V WETS. DISCLAIMER `' WELLS & WETS WATERSHED?& DRIVEWAIA (Elev) WATER LINE FDN DRAIN SCH40 t/ TESTS CURRENT? ,/ SOIL EVAL SEPTIC TANK MIN 150OG-1--- .17 INVERT DROP GARB. GRINDER 0(2 comps +200) 10' TO FDNL/ MANHOLE ELEV GW ## COMPS. � GB D -BOX SIZE ## LINES I�3 FIRST 2' LEVEL STATEMENT INLET_U -lZ - OUTLET = / 7 (2" OR .17 FT) TEE REQ'DA/6 LEACHING MIN 440 GPD? RESERVE AREA 4' FROM PRIMARY? 2% SLOPE 100' TO WETLANDS C/ 100' TO WELLS �'� 4' TO S.H.GW7Z (5'>2M/IN) 20' TO FND & INTRCPTR DRAINS 400' TO SURFACE H2O SUPP V 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL? (15') BREAKOUT MET? .� TRENCHES MIN 440 gpd SLOPE (min .005 or 6"/1001)_ W OR D (MIN 6') RESERVE BETWEEN TRENCHES? BE 10' MIN. 4" PEA STONE? VENT? BOT + SIDE (L x W x ##) Copyright 0 1995 by S.L. Starr SIDEWALL DIST. 3X EFF. IN FILL? MUST (>3' COVER; LINES >50') X LDNG = TOT (DxLx2x## ) ( G/ f t2 ) PITS MIN 440 LEACHING MIN 1 (13'x16') PIT MANHOLE/PIT GW MIN 4' BELOW BOTTOM EXC 2x EFF W OR D 12"-48" STONE BOT + SIDE x LOAD = TOTAL (L x W x ##) (2x(L+W)xD x ##) (G/ft2) CHAMBERS MIN 440 LEACHING GW MIN 4" BELOW COVER >3 FT - VENT MANHOLES 12"-48" STONE BED/TRENCH (Bed max. 60' X 60') SPLASH PADS SLOPE .005 MIN 13' X 16' PIT BOT + SIDE X LOAD = TOTAL (L x W x #) (2 x (L+W)xD x ##) (G/ft2) FIELDS MIN 440 GPD.Z 900 ft2 BED GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED? �"�4" PEA STON ? DIST LINE SLOPE .005? „ Z./ >3 COVER -VENT SCH 40 MIN 12 COVER` RATE MPI (� X �) X -loo = TOTAL��p0 I L W LDG DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. inlet) HWL LWL CHECK VALVE OP. SWITCH ENUF STORAGE? Copyright 0 1995 by S.L. Starr GW .(Min. 1' below BLEEDER HOLE MANUAL TOWN OF SYSTEM PUMPING RECORD DATE:_ SYSTEM OWNER & ADDRESS LD1 3okV66 Vl SYSTEM LOCATION (example: left front of house) DATE OF PUMPING: _ 3 QUANTITY PUMPED : C^) GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: L 5 n No. THE COMMONWEALTH OF MASSACHUSETTS FEE _ BOARD OF HEALTH OF a AA)r_> C-)Va Appliration for 4:30pofial 19�y,itrm Tom itrurtion ramit Application is hereby made or a Permit to Inst ) or Repair/Replace (V an ndividual Sewage Disposal System at: 7-0 l � 0H&) ;0 A. f 77 0 on -el- ,�? two i �o Z ��W © A) �T Owner Address Designer or Installer Address Type of Building Size Lot L7C} Sq. feet Dwelling — No. of Bedrooms Expansion Attic ( ) Garbage Grinder NO Other — Type of Building No. of persons Showers ( ) —Cafeteria ( ) Other fixtures Design Flow _� gallons per person per day. Calculated daily flow --:33 D gallons. Septic Tank — Liquid capacity EY JaVrOCLen44 Width � Diameter Depth Disposal Trt�eh — Width [Total Length Total leaching area 60 d sq. ft. Seepage Pit No. Diameter Depth below inlet Total leaching area sq. ft. Other Distribution box ( ) Dosing tank ( ) Percolation Test Results Performed by `°2>ZIR�&n Date �9 Q Test Pit No. 1 �� _minutes per inch Depth of Test Pit •, Depth to ground water Test Pit No. 2 minutes per inch Depth of Test Pit Depth to ground water Description of Soil L—� Nature of Repairs or Alterations — Answer when applicable Date Last Inspected Agreement: — The undersigned agrees to install the aforedescribed Individual Sewage Disposal System in accordance with the provisions of TITLE 5 of the State Environmental Code. The undersigned further agrees not to place the system in operation until a Certificate of Compliance has been issued byth oard of He th. S Signedx, .i �i qj 5o15 Date Application Approved By Application Disapproved for the following reasons: Permit No. Issued THE COMMONWEALTH OF MASSACHUSETTS BOARD OF HEALTH Trrtifiratr of Tompliana Date Date Date THIS IS TO CERTIFY, That the On -Site Sewage Disposal System installed ( ) or Repaired/Replaced ( on for at has been constructed in accordance with the provisions of TITLE 5 of The State Environmental Code as described in the application for Disposal System Construction Permit No. dated Use of this system is conditioned on compliance with the provisions set forth below: THE ISSUANCE OF THIS CERTIFICATE SHALL NOT BE CONSTRUED AS A GUARANTEE THAT THE SYSTEM WILL FUNCTION AS DESIGNED. This Certificate expires on DATE Inspector No. THE COMMONWEALTH OF MASSACHUSETTS FEE BOARD OF HEALTH Disposal it�g,strm Tomitrnrtion f rrmit Permission is hereby granted to to Construct ( ) or Repair/Replace ( ) an On -Site Sewage Disposal System located at Street as described on the application for Disposal System Construction Permit. The Applicant recognizes his/her duty to comply with Title 5 and the following local provisions or special conditions. All construction must be completed within three years of the date below. DATE FORM 1255 (REV. 4/95) H&W HOBBSB WARREN TM PUBLISHERS - BOSTON Board of Health THIS FORM APPROVED BY THE MASSACHUSETTS DEPARTMENT OF ENVIRONMENTAL PROTECTION 15,-,2Fvc - AlIq Y G 7-- 19z,)6 �9 �CAvf�,L -/�D 7 j a /-//t/ 5 O� L I • FORM 11 - SOIL EVALUATOR FORNI Page 1 of 3 No. Date: Commonwealth of Massachusetts Massachusetts Soil Suitability Assessinerzt or ort -site Se)wpe DjWosal 7� S Performed By: -- Date: d'�2g/9G Witnessed By: ..2 .S� e e 707 r0tfA60AJST ,ked..,.. e �Po tei�ybs, 79q /GZ OL ew Construction ❑ Repair l�!' Office Review_ Published Soil Survey A%ailable: No ❑ lFes PI -K Year Publishedjll� l7 Publication Scale C y—L4 e- 7 Soil Map Unit Drainage Class Soil Limitations A).e A)C7 Surficial Geologic Report Available: No ❑ Yes ❑ Year Published Publicatic i Scale GeologicMaterial (N -lap Unit) ........................._................................................._.............._ ...... Landform........ ......... .... ........................................... ....._.._ ................................. ......... ..................... ._.... Flood Insurance Rate Map: Above 500 year flood boundary No ❑ YYes Within 500 year flood boundary No F 1 Yes ❑ Within 100 year flood boundary No Kyes U Wetland Area: National Wetland Inventory Map (map unit) _..._.............................................. Wetlands Conservancy Program Map (map unit) ............:........... ...................... Current Water Resource Con itions (USGS): %Iontli Range :Above Normal F..LNormal UBelow Nonnal U other References Reviexed: DEP APPROVED FORM - 12/07/95 k) 11 UP Page ' of 3 Location address or Lot :vo. J22MNSOiJ s On-site Review Deep Hole Number / Date: &/09/96 Time: //4%0 d Location (identify on site plan) k) Land Use (_A�%tiJ/J Siope (°!o) S4)10 Surface Stones Vegetation 6leASs Landform Ho2t'l/mac _ q Position on landscape (sketch on ;he back) Distances from: Coen Water Body feet Orainage way N hA feet Possible Wet Area N%A feet Property Line 07_1 feet Drinking Water Well feet Other Weather Cly Af do DEEP OBSERVATION HOLE _OG' Deoth irom1 Sur -ace (Inc^es) Soil Horizon Scii -exture USOAi Soii Color (Munsell) Soil Mottling I Other i (Structure. Stones. Boulders. Consistency, % Graveil 36- -4-10f- tCS L 1,01/2 71/ y& - A ga y,_ �4 N1114IIVIVIVI Vr G 1 LQZI �QuU ncV 11 Q"CIS 1 rnvry JCV V1JrVJMI M!\CM Parent Material (geologic) OepttttoBedrock: Oeoth to Groundwater: Standing Water in the Hole: Weeping from Pit Face: Estimated Seasonal High Ground Water:— DEF A.PPROVED ater: DEP,.PPROVED FO"t - 12107195 03-21=1996 14:36 617 932.7615 - OEP NCP TNEAST.nEGi'CNAL F Depth of Perc at...e .. ...,.a. y+..F. aw:..set •. .�^�:� �*' � _-. _��' J r[F6niL 5F3fc.w—a. "e T' �r.�e3.�S-Y-L•!' � a:t ^,+y ::.^^..•�^ �r�r..e�:++-a.. +� - a..�,-..-rxss-- -,ww+� -• .: � t� a_:HT :��r. FJ....rZ c� "F - Erid Pre-soak / Z Time at 12" _ _FORM 1' PERCOLATION M Time at 9" Time at 6" // I (f Time (9"-6") Location Address or Lot'Na. Rate Min./inch y� ,�- COMMONWEALTH OF MASSACHUSETTS Massachusetts - - Percolation Test' Date; Time: Observation Hole : -- Depth of Perc �r �s Start Pre-soak Erid Pre-soak / Z Time at 12" _ Time at 9" Time at 6" // I (f Time (9"-6") Rate Min./inch 61-1 ' Minimum of 1 percolation test must be performed in both the primary area AND. reserve ar a. Site Passed Site Failed ❑ ��.................. __........ ................... ..............._............................................ ........... Performed By: _ D 0 Witnessed By:`. Comments: _ ...: ..._................ _. nv XFMOvm r0sw - Ul"195 4 1 1 ' • s t- Location Address or Lot No. li'011M ! 1 - soil, LVALUATOR POMII Page 3 bf 3 70-7 J-0tW-sad Determination for Seasonal High Water Fable Method Used: ❑ Depth obsetved standing in observation hole .. inches epth weeping from side of observation hole.. inches Depth to soil mottles 66 inches ❑ Ground water adjustment ................... feet Index Well Number .............. Reading Date ................ Index well level.... . Adjustment factor Adjusted ground water level .. . .. . Depth of Naturally Occurring Pervious Material Does at least four feet of naturally occurring pervious material exist In ap great, observed throughout the area proposed for the soil absorption system? If not, what is the depth of naturally occurring pervious material? — Certification I certify that on l li'�% (date) 1 have passed the soil evaluator examination approved by the Department of Environmental Protection and that the above analysis was performed by me consistent with the required training, expertise and experience described in 310 CMR 15.017. Signature <�Date3. �.6 UEP APPRO%-ED FORM - 12101195 FORR4 9B - LOCAL LTGRADE APPROVAL Commonwealth of Massachusetts Massachusetts LOCAL UPGRADE APPROVAL ISSUED PURSUANT TO310CMR 15.404 & 15.405 Facility/system owner: Name: �APON I Address: %p -7V OWNS aN Address of facility MCS" Type of facility:. residential `� institutional —commercial _ school design flow per 310 CMR 15.203 330 gpd System designer: Name Address ZZ L«< SON -C� Phone No. 3SZ 7Z oK Ai4 0/9zI Local Upgrade Approval granted for: reduction in setback(s) (specify) /0 � FIFOJL A f3 perc rate of 30-60 min./inch (specify rate) _ reduction in SAS area of up to 25% (specify % reduction & size of SAS) reduction in separation between .6 I'q /?C0 (JGL— TO -3,o7,. SAS & high groundwater (specify reduction & perc rate) relocation of a well (explain) List local variances granted (no DEP approval required per 310 CMR 15.412(4)) List variances granted requiring DEP approval Board of Health Approval of proposed upgrade Signature City/town Name & Title. Date THE SYSTEM OWNER UR OPERATOR SHALL PROVIDE A COPY OF THIS LOCAL UPGRADE APPROVAL TO THE APPROPRIATE REGIONAL OFFICE OF THE DEPARTMENT OF ENVIROINMENTAL PROTECTION DIVISION OF WATER POLLUTION CONTROL UPON ISSUANCE BY THE LOCAL APPROVING AUTHORITY & BEFORE COMMENCEMENT OF CONSTRUCTION. DEP APPROVED FORM - 12/017/95 Septic Compliance, Inc. affilliate of Thomas E. Neve Assoc., Inc. March 13, 1996 Ms. Sandy Starr Board of Health 146 Main Street North Andover, MA 01845 Re: Sanitary Disposal System Inspection Elizabeth and Alberto Raponi - 707 Johnson Street Dear Sandy: nry MqR , 51996 In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a "Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents, please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTIC COMPLIANCE, INC. <F. NkNe Thomas E. Neve, PE, PLS President Attachment SCI #029 CORRES.WPS • SYSTEM INSPECTORS • • SOIL EVALUATORS • • ENVIRONMENTAL ENGINEERS - 447 Old Boston Rd., US Route 1, Topsfield, MA 01983 Tel (508) 887-8586 Fax (508) 887-3480 Property Address: Date of Inspection: Name of Inspector: Septic Compliance, Inc. affilliate of Thomas E. Neve Assoc., Inc. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 707 Johnson St. No. Andover,Ma. 01845 February 23, 1996 Thomas E. Neve, PE, PLS Company Name, Thomas E. Neve Associates, Inc. Address and 447 Old Boston Rd., Topsfield, MA 01983 Telephone Number: (508) 887-8586 Address of Owner: (if different) Certification Statement 1 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 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: Passes Conditionally Passes Needs further Evaluation By the Local Approving Authority X els Inspector's Signature: ���`�y_ Date: 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 report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority. • SYSTEM INSPECTORS • • SOIL,EVALUAa'ORS - • EMgRONMENTAL ENGINEERS - 447 Old Boston Rd., US Route 1, lbpsfield, MA O 983 Tel (508) 887-8586 Fax (508) 887-3480 s SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 707 Johnson St. No. Andover, Ma. 01945 Owner: Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 INSPECTION SUMMARY: Check A, B, C, or D: A) SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B) SYSTEM CONDITIONALLY PASSES: One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes inspection. Indicate yes, no, or not determined (Y,N, or ND). Describe basis of determination in all instances. If "not determined", explain why or The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, tank failure is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as approved by the Board of Health. 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 leveled 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): 2 Broken pipe(s) are replaced Obstruction is removed SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 707 Johnson St. No. Andover, Ma. 01845 Owner: Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 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 the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS THE BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER THAT PROTECTS 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT. The system has a septic tank and soil absorption system and is within 100 feet to a surface supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet or more from a private water supply well, unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 707 Johnson St. No. Andover, Ma.01845 Owner: Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 D) SYSTEM FAILS: X 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 contact to determine what will be necessary to correct the failure. N Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Y Discharge or ponding of effluent to the surface of the ground or surface water due to an overloaded or clogged SAS or cesspool. Y Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. N Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow. N 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 N elevation. N Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 707 Johnson St. No. Andover, Ma. 01845 Owner: Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 D) SYSTEM FAILS (continued) N Any portion of a cesspool or privy is within a Zone 1 of a public well. N Any portion of a cesspool or privy is within 50 feet of a private water supply well. N 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 systems 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 exists: The system is within 400 feet of a surface drinlang water supply. The system is within 200 fuet of a tributary to a surface drinlang 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. 5 - SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 707 Johnson St. No. Andover, Ma. 01845 Owner: Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 Check if the following have been done: Y Pumping information was requested of the owner, occupant, and Board of Health. Y None of the system components have been pumped for at least two weeks and the system has been receiving normal flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. N/A Asbuilt plans have been obtained and examined. Note if they are not available with N/A. Y The facility or dwelling was inspected for signs of sewage back-up. Y The system does not receive non -sanitary or industrial waste flow. Y The site was inspected for signs of breakout. Y All system components, excluding the Soil Absorption System, have been located on the site. Y The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. Y The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. Y The facility owner land occupants (if different from owner) were provided with information on the proper maintenance of Subsurface Disposal System. 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 707 Johnson St. No.Andover, Ma. 01845 Owner: Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 FLOW CONDITIONS RESIDENTIAL Design flow: 330 gallons Number of bedrooms: 3 Number of current residents: 4 Garbage grinder (yes or no): yes Laundry connected to system (yes or no): yes Seasonal use (yes or no): no Water meter readings, if available: Lastdate of occupancy: occupied C OMMERC IAL/INDUSTRIAL: Type of establishment: Design flow: Grease trap present (yes or no): Industrial Waste Holding Tank present (yes or no): Non -sanitary waste discharged to the Title V system (yes or no). Water meter readings, if available: Last date of occupancy: OTHER (Describe): Last date of occupancy: 7 gallons/day SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 707 Johnson St. No. Andover, Ma. 01845 Owner: Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 GENERAL INFORMATION PUMPING RECORDS and source of information: According to Home owner system was pumped three months ago. System pumped as part of inspection (yes or no): yes If yes, volume pumped: 1000 gallons Reason for pumping: To inspect integrity of the tank, to check for water tight-ness, to check tee,s. TYPE OF SYSTEM X Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or not) [If yes, attach previous inspection records, if any] Other (explain) APPROXIMATE AGE of all components, date installed (if known) and source of information: I would estimate 25 to 30 years of age. unknown self estimation Sewage odors detected when arriving at the site (yes or no): slight odor SEPTIC TANK: ves (locate on site plan) Depth below grade: 2.5 ft. Material of constniction: X concrete metal FRP Other (explain) 8 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 707 Johnson St. No. Andover, Ma. 01845 Owner: Elizabeth and Alberto Roponi Date of Inspection: February 23, 1996 Dimensions: 8' 0" x 5' 1 " x 5' 4" Sludge Depth: 3" Distance from top of sludge to bottom of outlet tee or baffle: F 10" Scum thickness: 2" Distance from top of scum to top of outlet tee or baffle: 5" Distance from bottom of scum to bottom of outlet tee or baffle: 1' 9" Comments: (recommendations for pumping, condition of inlet and outlet tees or baffies, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) Tank should be pumped at least once per year, tank had no signs of leakage,no problem with tank and it,s componants. GREASE TRAP: none (locate on site plan) Depth below grade: Material of construction: Dimensions: Scum thickness: Concrete Metal FRP Other (Explain) Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 707 Johnson St. North Andover, Ma. 01845 Owner. Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 Comments: (Recommendations for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) TIGHT OR HOLDING TANK (locate on site plan) Depth below grade: Material of construction: Dimensions: Capacity. Design flow: Alarm level: Concrete Metal FRP gallons gallons/day Comments: (Condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: ves (Locate on site plan) 10 Other (explain): SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 707 Johnson St. North Andover, Ma. 01845 Owner: Elizabeth and Alberto Rapom Date of Inspection: February 23, 1996 PUMP CHAMBER (Locate on site plan) Pumps in worldng order (yes or no): Comments: (Note condition of pump chamber, condition of pumps and appurtenances, etc.) SOIL ABSORPTION SYSTEM (SAS): yes (Locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: The field in my determination has to be replaced. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 707 Johnson St. North Andover, Ma. 01845 Owner. Elizabeth and Alberto Raponi Date of Inspection: February 23, 1996 Type: Leacan1g needs; number, dimensions:' Leaching facility was not found. OvetflaR%_cesspool, n�ber. Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) verywet yes no normal Candmon were very wet. A small hole was put in the outlet pipmg next to the septic tank. The pipe was 1/4 fall with no flow oocurring from the septic tank to the leaching facility_ CESSPOOLS: (Locate on site plan) Number and configuration: Depth4op of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of constriction: Indication of groundwater: Inflow (cesspool mast be pumped as part of inspection): 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 707 Johnson St. North Andover, Ma. 01845 Owner. Elizabeth and Alberto Roponi Date of Inspection: February 23, 1996 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.): 13 SKETCH OF SEWA IncWd-c Locate Jar. Ac=//" '� C- = ZV" &AG,z Zia` -,U 14AIN "kt 4 2 A, ,04 7 t V rr, IV, -- "k. - - X in ce-- P'. .-z , " - -1 , L15" 41., ;W -.r f V X, W4r.4 v P4 M.N ""i'o 7 0 Y. 0 FA kz Z.14 JL 7' Exact location of leaching area undetermined; approximate location shown. No ponding but soggy. soil surface found. Recommend leaching area replacement and disconnecting. garbage grinder.-=. DEPTH TO GROUNDWATER Depth to groundwater: feet Method of determination or approximatio& �"--Seems to be >4' -from bottom of system. .1 14 Name of Inspector Thomas E. Neve Company Septic Compliance, Inc. Address 447 Boston Street, Topsfield, MA 01983 (508) 887-8586 - .r ..; r .S• w r -,r L 'st s' l.,.x i ; , �e x.< . • .�. !r t�"s._. y t _ v. r• r.°. t ii 'r.A. ^`�Qxh t'„f. e`1.- r w,. w I.Gl W1lCiahon JUl1.Glllent, •s `' >`�'. -Ji i�,y'f , } t �+ { r'� -r�,�E r: i'� s r�,y r N .. w" .. W �� .. � v -� ,r � � �� �'°sf. � � i�+. "t S ,.Z ' 4 1 s -1 ,��' {�( �^ n9i•,�,' .� '. 1' +r �a-�*:�y,-, t, Y xt} .E -r-`., tax 7,- « y,. { s.. '` .t i•y i�fY'rk '�_µ t;t. :.J' k.v ,,��,-:3 \ {}s s� �:' r�' �r+s'�..,r, 'dam Y.v:ai;,:° t w ¢a.*,y ' -, f 3 L. st'i win,.a#° ` Iy a.e�4„;•r ,�r'”y.±:�zAz'" `-..r that I have personally mspectedYthe sewage disposal'systeiii at this address and that;the mformahon reported is true, accurate and complete as of the tune -of mspechon. Tlie .g�` 4x ` 'rnied and ant onwas o recommendafions re dtn t c .; ,�, .�r gar g upgrade, maintenance and repair, are cons�stem with my framing and experience m x r - e _4 , the nchon and maintenance oft n r PI'oP o site sewage sal sy(�p�e z Check one - I have not fomul anyinfomiation which indicates that the sjrstem fails to adequately protect:pubhc health or the environmentIas defined in 310 CMR 15.303. Any failure criteria not evaluated are as :stated in- he FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 XX CMR 15.303. The basis for this determination is provided in the FAILURE CRITERIA section of this form. Inspector's Signature: Date: Copies to: Buyer (if applicable) Approving authority. February 23, 1996 Board of Health 15 Sherwood^Homes �J Lot 6, Johnson St. APPLICATION FOR SEWAGE DISPCSAL IMTAIJATION HEALTH DEPARTMENT - NORTH ANDOVER, MASS. I hereby make application for a permit for a sewage disposal installation at Sh Lot 6, Johnson St. . I will install this system in ac- cordance with all the laws of the Commonwealth of Massachusetts and regulations of the Board of Health of the Town of North Andover. Further, I will construct the house sewer of bell and spigot pipe, the minimum diameter being 4 inches, and will maintain a minimum grade of 116 until 10 feet pre- ceding the septic tank, where the grade shall not exceed 2%. I will install a con- crete septic tank of 1000 gal,* in size. A manhole (s) permitting easy cleaning will be provided with removable cover (s) of iron or concrete within 12 inches of the ground surface. I will provide subsurface disposal field with 4 inch perforated or open jointed pipe and laid in a series of trenches, the bottom of which will pro- vide a minimum of 200 lineal O feet of effective absorption area. The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar material to a height of 2 inches above the crown of the pipe. The joints of these pipes will be protected from clogging and before filling the trench, 2 inches of gravel or stone 1/8" to 1/4" (dia.) will be placed over the course gravel or stone. The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single tile line will exceed 100 feet in length and in any case, two lines of tile will be installed. A minimum of 6 feet will be maintained between the center lines of the disposal field trenches and the average depth of trench shall not exceed 36 inches. No part of the installation will be less than 100 feet from any private water supply, 25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line. I further agree not to cover any portion of this installation until approved by the inspection officer, as provided below, and to incorporate any additional requirements that may be attached to the permit. Plot Plans must be submitted with application. DATE 11/27/61 Signature of Applicant J—Zk-4!5c4 I hereby issue the above permit for tfi�toard of�ealth of the Town of North Andover, Massachusetts. DATE 11/27/61 f0�Signature of Health Agent I have inspected the uncovered system indicated above and find everything done as described. DATE -2-3 Z- -a3- Percolation Test _� � min. Soil: Clay Garbage Grinder No s Signature of I cting Officer -, November 18, 1961 Miss Mary Sheridan R. N. Health Agent Board of Health North Andover, Mass. Dear Miss Sheridan: An examination was made as requested in order to determine the suitability of the soil for the subsurface disposal of sewage on the proposed Johnson Street, Lot #6, building site of Sherwood Homes, Inc. The land in general is high. The subsoil in the area was of clay content and a 5 -minute percolation test was taken. It is recommended that a 11000 gallon concrete septic tank be installed together with 200 lineal feet of drain pipe. Very truly yours, UWiialm J. iscoll C--O'-'f WJD:hd 3"1 BOARD OF HEALTH TOWN OF NORTH ANDOVERV 11ASS. z2G 30 a y �tt y :OX -- /A�_o 1 NAME .ShfrAle00l A0�fs 1 h� DATE /1 "7- C/ . . . . .--�I . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. ADDRESS .. LOT NO. . TEL. . 3, N0. OF BEDROOMS `-3. . DEN YES . . .0 N0. l,. GARBAGE GRINDER. YES NO. /ox . • 5. SHOW DIDJENSIONS OF HOUSE 6, SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES 7. SHOW DIVENSIONS OF LOT - �f�^ 5�,,,/�ar� �`i�rS 8. -SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL "`� 9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM 10. SHOW LOCATION OF BROOKS 9 STREAMS 1, DITCHES $ LEDGE OUTCROPt ETC. 11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROTI HOUSE NOTE: LOCAL REGULAT IOVS SHOULD BE READ CAREFULLY. TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: Y'S --01 (example: left front of house) n5 DATE OF PUMPING: O QUANTITY PUMPED GALLONS CESSPOOL: NO S SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE &"� EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: P) CD�� F -,J COMMENTS: CONTENTS TRANSFERRED T TO: 6, L Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. rdaa Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record JUN 1 1 2007 Form 4 TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other fo stt€da��irtt� information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System N 6 on: <31 GIZ- lAot-j Address � � --7 Citylrown State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State A9-Code �� Telephone Number 5-31 --C)'7 Date 2. Quantity Pumped: Cs-�� Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 0-J;Vo if yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: ��-&k t t - —�� n 6. System Pumped By: Name Vehicle License Number Company 7. Locatio ere contents were ^dNsed: Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of Zusingg IVE System Pumping Record 6 2009 Form 4 TH ANDOVER DEP has provided this form for use by local Boards of Health. Other information must be substantially the same as that provided here. Be 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: s^ When filling out 1. System Location: Left front, left rear, left side of house. Right front, right rea , Ight side of hous forms on the - computer, use only the tab key Address ; �p i to move your t cursor - do not use the return Citylrown . State Zip Code key. _ 2. System Owner: Name Address (if different from location) City/Town Stater— Cocle Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: 8 Cesspool(s) eptic Tank [j Tight Tank Other (describe): 4. Effluent Tee Filter present? Cj Yes 2-90 If yes, was it cleaned? Yes No 5. Condi(-o�.f�Sy1 a"A— 1 (4e 6. System Pumped By: Neil Bateson F 5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locati re contents were disposed: L.S.D Lowell Waste Water igna ure of 1-141hr Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 ,PC - Commonwealth of Massachusetts -_-� F City/Town of IVIED System Pumping Record AN 4 [011 Form4 . `�M Vey,W TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Healt . tt3l, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name V `� Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ 4 Stat _ �jZip Code , -i i / Telephone Number 6 - i( Date 2. Quantity Pumped: Cesspool(s) ❑--S ptic Tank ❑ Other (describe): Effluent Tee Filter present? ❑ Yes 5. Condition of System: f G�U . f ✓luC 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No f'�4's F5821 Vehicle License Number t5form4.doc• 06/03 System Pumping Record, Page 1 of 1 Commonwealth of Massachusetts L ED City/Town of System Pumping RecordForm 4 NpOVER MENT DEP has provided this form for use by local Boards of Health. Other forms may be us , but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house, Left / ' ht side of house Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under dec c Address City/Town State Zip Code " V 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Conditiqn of System: a rq1-t- 6. System Pumped By: Neil Bateson State Kip, Cede Telephone Number "C — 2. Quantity Pumped: Septic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Name Bateson Enterprises Inc Company 7. Locati re contents were disposed: 'G. L. S. V Lowell Waste Water t5form4.doc• 06/03 F5821 Vehicle License Number - Date -(a -[a System Pumping Record • Page 1 of 1