HomeMy WebLinkAboutMiscellaneous - 71 WILLOW RIDGE ROAD 4/30/2018 (2)ip
Commonwealth of Massachusetts
_ City/Town of
0
System Pumping Record OCT os 203
_BOARD OF HEALTH
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, Left / right side of house, Left /
Right side of building, Left / Right front of building, Left / Right rear of building, Under deck
Address
Wq(C)W' N� -"Cityrrown to Zip Code
2. System Owner. f
1
Name
Address (if different from location) t
Cityrrown StateCode -tea -
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank
❑ Other (describe): l
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No.
5. ConditicKt pf Syste� m 1
�U l V\'
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Loca ' re contents were disposed:
Lowell Waste Ws
01.
v
uleq j Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
ICN Commonwealth of Massachusetts LOF
fin
City/Town of
System Pumping Record '12
U11
Form 4
' NDOVER
DEP has provided this form for use by local Boards of Healmus d, 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 Locatio eft front of house right front of house, left side of house, right side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
<<N - )W')Ve-C
City/ Town State
2. System Owner:
�c«
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Zip Code
State Zip Code
Z; -�
Telephone umber
t
Date 2. Quantity Pumped: Gallon L OC7
Cesspool(s) [SI/Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes [], No
5. Condition of System:
o� �I
6. System Pumped By:
Neil J. Bateson
Name
Bateson Enterprises Inc.
Company
7. Loc where contents were disposed:
G.Lowell Waste Water
L.v.r
Signature of Hauler
If yes, was it cleaned? ❑ Yes ❑ No
F5821
Vehicle License Number
'3 -'2 (:;, ' ( /
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
�LN Commonwealth of Massachusetts
City/Town of
System Pumping Record
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
MAY 2 2 2006
TOWN CF rNk;R
DEP has provided this form for use by local Boards of Health —The. ysterri
be submitted to the local Board of Health or other approving authority. .
A. Facility Information
1. System Location.
VER
City/Town t� State r
Zip Code
2. System Owner: 1rA1
4- l
Name
Address (if different from location)
City./Town State Zip C6de
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantify Pumped:
Gallons
I Type of system: ❑ Cesspool(s) ❑optic Tank- ❑ Tight.Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes t f'No If yes, was it cleaned?
❑ Yes ❑ No
5. Condition of System:
6. Systep P trlped By.
Name V -L, '
CompanyAi . --
7. Locatio here contents we
rerposed:
i✓ `j - VJ
...y..,.... r.. 7r-1
http://www.mass.gov/dep/Water/approvalt,/t5forms.htm#inspect
t5form4.doc• 06/03
Vehicle License Number
Date
System Pumping Record • Page 1 of 1
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address:71 wi 1 1 nw u; dne n,. a
N A��=.pr,�18 0704a ---
Owner's Name: w,,,, i . F I
Owner's Address: same O
Date of Inspection:
Name of Inspector: (please print) agh J.Shji y
Company Name: Soucy' s SgWer • Sprvi ce Inc.
MailiagAddress: 830 Livingston Street
Telephone Number.
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 tis don 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:
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
721Z
Inspector's Signature: _.4 Id Z111r, Date:
The system inspector shall submit copy of thisi pectior�port to the Approving Authority (Board of Health or
DEP) within 30 days of completing this mi Vectio . If the system is a shared system or has a design flow of 10,040
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 hpw the system will perform In the future under the same or different
conditions of use..
Title S Inspection Form 6/15/2000 - page 1
Pyle 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddreu: 71 Willow Ridc ee Road
N.And vc�er,MA 01845
Owner: TCP -vin
.
Date of Inspection;44
-�
Inspection Summary: Check AAC,D or E / &1&&YS complete all of Section D
A.Sy m Passes:
1 have trot 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:
Quo ormore system components as described in the "Conditional Pass" section need to be replaced or
repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass.
Answer yes, no or not determined (Y,N,ND) in the for the following statements. If "not determined" please
P
The septic tank is metal and over 20 yeah 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:
P10 Observation of sewage backup or break out or high static water level in the distribution box due to broken or
Obstructed pipes) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipo(s) aro replaced
obstruction is removed
distribut* box is leveled or roplacod
ND explain
P The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
PUS inspection if (with approval of the Board of Health):
broken pipe(s) aro replaced
obstruction is removed
ND explain:
Page- 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 71 Willow Ridge Road
N . Andover,MA • 01 8
Owner:
Date of Inspection:
C. Further Evaluation is Required by the Bard of Health:
Conditions exist which require Rather evaluation by the Hoard of Health in order to determine if the system
is failing to protect public health, safety or the environment.
1. System will pass Rales Bard of Health determines in accordance with 310 CMR 15.303(lxb) that the
system is not functioning 0 a scanner which will protect public health, safety and the environment:
_ Cesspool or privy is within so feet of a surface water
— Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fait unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a scanner that protects the public health, safety and environment:
_ The system has a septic too 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 feat or more from a
private water supply wells*. Method used to determine distance
•'This system Passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than S ppm, provided that no other
failure criteria are triggered. A copy, of the analysis must be attached to this form.
3. Other:
E<3
Page •4, of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: _71 Willow Ridge Road
Owner.
_N-Andiwer,NA, -
01845
Date of Inspeetlon:
D. System Failure Criteria applicable to all systems:
You ig uidicate "yes" or "no" tq each of the following for ALinspections:
Yes No
._ -'L Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool
Discharge or ponding of et UNI! to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool .
_tz Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
-- -IC Uquid depth in cesspool is less than b" below invert or available volume is less than �/: day flow
-jZ Required pumping more than 4 times in the last year V.QT.due to clogged or obstructed pipe(s). Number
of times pumped
-&L Any portion of the SAS, cesspool or privy is below high ground water elevation.
,. --,t Any portion of cesspool or privy is within 100 feet of a surf
water supply. we water supply or tributary to a surface
1
Any Poon of a cesspool or privy is within a Zone 1 of a public wen.
-' 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
supply well with no acceptable water greater than SO feet from a private 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 L free from pollution from that facility and the presence of ammonia
nitrogen and nitrate nitrogen Is equal to or less than S ppm, provided that no other failure criteria
an triggered. A copy of the Analysis mud be attached to this form.]
(Ye3/No) The system fg(]f. 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' necessary to correct the failure.
L Large Systems:
To be considered a large system the system must serve a facili
gPth ty with a design flow of 10,000 End to 15,000
You must indicate either' Yes" or "no" to cub of the following;
(The following criteria apply to large systems in addition to the criteria above)
yes no
Y-tthtem is within 400feet ofa surface drinking water supplytem is within 200 feet of a tributary to a surface driplciag water supply
tem is located in anitrogensensitive arca (Interim Wellbead Protection Area - IWPA) or a mapped
oneII 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 hes 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.
Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE, SWAGR DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: _:11 bli l 1 nw R; {fig—Road
Owner:� F„ „�,,,
N.AMA0178-ro MA 01 45
Date of Inspec ion T '=�'— =9 -aa
Check if the following have been done. You must indicate `yes" or "no" as to each of the following:
Yes No
_ V Pumping information was provided bythe 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 ?
uC 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 ba es or tees, material of construction, dimensions; depth of liquid, depth of sludge and depth of scum ?
-Al -�,_ %Vas the facility owner (and occupants if different from owner) provided with information on the
maintenance maintenance of subsurface sewage disposal systems ? p oper
The size and location 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 I 1
OFFICIAL INSPECTION FORM - NOT FOR -VOLUNTARY ASSESSMENTS
SUBSURFACE -SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C.
SYSTEM INFORMATION
Property Address: 71 W 11 i d goad
Owner: NA 4 5
Date of Inspection: -
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): A .: Number of bedrooms (actual):
DESIGN flow based on 310 CMR 15.203 (for, example: 110'gpd x # of bedrooms): I kwo
Number of current residents: ILI_
Does residence have a garbage grinder (yes or no): kiv
Is laundry on a separate sewage system (yes or no): do—, [if yes separate inspection required]
Laundry system inspected (yes or no):
Seasonal use: (yes or no): jiv
Water meter readings, if available (last 2 years usage (gpd)):
Sump pump (yes or no): %40
Last date of occupancy:
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.20 : and
Basis of design flow (seats/persons/sq%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/user_
OTHER (describe)
GENERAL INFORMATION
Pumping'Records
Source of information: _0
Was system pumped as Wk of tHe inspection (yes 4r 2titv
If yes, volume pumped: allons -How was pumped det rmined? OA
Reason for pumping: WIMA do 1! Gazer AP--oc-10"
TYreptic;
F SYSTEM
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):
Approximate age of all components,dto installed (if known) and source of information:
Were sewage odors detected when arriving at the site (yes or no): AD
6
Page 7 of 11
OFFICIAL INSPECTION -FORM, NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE_ DISPOSAL'SYSTEM INSPECTION FORM
PART .0
SYSTEM INFORMATION (continued)
Property Address: 71 Willow Ridge Road
N.Andover, M 1845
Owner: Kevin Flynn
Date of Inspection: —O 0
BUILDING SEWER (locate on site plan) ..:.
Depth below grade:
Materials of construction: cast iron r,1 °fQ PVC ,other (e*p lain):_
Distance from private water supply well or suction line: N'f f�
Comments (on condition of joints, venting, evidence of leakage, etc.):
SEPTIC TANK: (locate on site plan)
Depth below grade: _(A
Material of construction: ncrete
_other(expl_metal,__,_fiberglass ___polyethylene
ain)
If tank is metal list age: _ . Is age confirmed by a Certificate of Compliance (yes or no):
certificate) _ (attach a copy of
Dimensions: 1k' S-ra�
Sludge depth:
Distance from top of s udg oto bottom of outlet tee or baffle: 36��
Scum thickness: It: ;, c: '4p I'! 0 .. , " "I :.
Distance from top oiscum to top of outlet tee or baffle:n
Distance from bottom of south to bottom. of outlet tee or baffle:. r
How were dimensions determined:
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to n„tlnt;nu..* ..,.A ---`-
Depth below grade: _
Material of construction: —concrete metal fiberglass
(explain): polyethylene _other
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
Page 8 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL' SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 71 .Wi 1 1 nw Ridge Road
N- ox,Ar, MA01845
Owner: - -Kevin ,!z.an
Date of Inspection:
TIGHT or HOLDING TANK: �4tank must be pumped at time of inspection)(locate on site plan)
Depth below grade:
Material of construction: concrete metal fiberglass ,polyethylene other(explain):
Lnnensions• —
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: Zif present must be opened)(locate on site plan)
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.): w A j ,
PUMP CHAMBER:6ocate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
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: 7_1_ wit 1 o Ridge Road
N - Aprjn t=rj�ji A QJ $45
Owner: �c�u Fljrna_
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:
�eaching trenches, number, len
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.):
CESSPOOLS: A4(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 or no):
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.):
PRIVY ocate 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
PARTC:
SYSTEM INFORMATION (continued)
Property Address: 71 Willow Ridge Road
N_Andover, MA 01845
Owner: _ t{pv; n F1 nn_,_
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM
Provide a sketch- of the sewage disposal system including ties to at least two permanent reference landmarks or
benchmarks. Locate all wells within, 100 feet. Locate where public water supply enters the building.
Pwiloffl
OMCL 6L INSPECTION FORM _ NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTBM INFORMATION (ooatinwo
Property Addmw1 _71 Willow Ridge Road
MA..QJ 8 4 5
Dow of lespidoil
SITE ZxAhl
Swim wow /
Cheek CsHw
Shallow wwu
Ertimeted 4OP6 to ground wear Xhu
Pkate bWkAW WOW AN 01*69b wed 10 det MkW the high Wgwd water ekvWon:
:toss rJam dNign AW 04 Mord - If aMohed„ 4W of deem PM viewed;
aiu (abuag WOMY/Ohn O" hole W"t i0 tM of SAS)•%"
._. ChrAw wm wd Dowd of �hbq�ChKked _
Acoweed fth WOW ""Va o % teaavh documa1te11oa)
1I
Town of North Andover
Office of the Health Department
Community Development and Services Division
27 Charles Street
North Andover, Massachusetts 01845
Sandra Starr
Health Director
May 29, 2002
Mr. Michael and Mrs. Darlene Flinn
71 Willow Ridge Road
North Andover, MA 01845
Re: Application for an addition and deck to an existing home
Dear W. and Mrs. Flinn:
Telephone (978) 688-9540
Fax (978) 688-9542
Your application for an addition and deck at 71 Willow Ridge Road has been reviewed by the Health Department.
The application was denied on May 29, 2002 for the following reasons:
1. X Missing information
2. X Passing Title 5 inspection of septic system may be required
Location of structure not acceptable
To address the problem(s):
If #1 is checked, please supply:
a. Floor plan of the existing dwelling and the proposed addition;
b. Certified plot plan showing house, septic system and proposed project in scale.
If #2 is checked:
a. Have the septic system inspected by a certified Title 5 inspector to determine the size of the
system and whether it is operating properly: OR
b. Tie-in to municipal sewer.
If #3 is checked:
a. The proposed project may cover part of the system and cannot be determined without a certified
plot plan showing the locations of the system and the addition.
Please feel free to call the Health Office at 978-688-9540 with any questions you may have.
Sincerely,
n
ni J. LaGrasse,
Health Inspector
cc: Building Department
File
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 NURSE 688-9543 PLANNING 688-9535
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AAI
Commonwealth of Massach setts
(� •✓�� , M. ssachusetts F RECEIVED
System Owner
-1 � WA[()W R11j, C
Date of Pumping:
Cesspool: No Yes [I
System Pumped by: F4ted4ct
OCT 19 2004
Record TOW 0TH DEPARTMENTER
System Location
�
�-�
Quantity Pumped: 1 aOO gallons
Septic Tank: No [ ]
License #
Contents transferred to: Greater Lawrence Sanitary District
Date: `Q` — d j Inspector:
Yes [
//
Commonwealth of Massachusetts— - -
k9iCity/Town of i
System Pumping Record OCT 15 2007
Form 4
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
VIC]
ILEI
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: e), 4— �c�P
Address (�jw
Cityrrown State Zip Code
2. System Owner:
1�V\V\
Name
Address (if different from location)
City/rown
B. Pumping Record
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
StateZip Code
q 175 -�
Telephone Number
Date 2. Quantity Pumped
Cesspool(s)eptic Tank
J6-'e-�
Gallons
❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No
5. Condition- System:`'e. �l
6. System u By:
Name � Vehicle License Number
Company
7. Location whewoontents di d:
Date
t5form4.doc• 06/03 System Pumping Record • Page 1 of 1
it
G7
TO: NORTH ANDOVER, MASS
BOARD OF HEALTH
FROM: DESIGN ENGINEER
r1l Z- 19 77
Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
4— %` /7 CGIlldc.0 R, North Andover, Mass.
SITE LOCATION
i
The grades and construction are as specified in my plans and specifications dated
z/ Z
do
.
SOIL PROFILE &
TEST DATA
Townty' No. &Stree t _ _. Lot No. 17
Loc./Subdiv. .�¢.G� �GYr'G' Plan Owner ✓-
Investigator��.-.�C��lv Observer
r
SOIL PROFILES -DATE
1.
Elev. Z-2 Elev. Elev. =E1ev.
n o 0
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Benchmark Location
Elevation Datum
Percolation Tests -Date 9 /6 G
Pit Number
1 2 3 4 5
St -art Saturation
3
Soak -Mins.
,rjrn
Start Test -Time
z
Drop of 3" -Time
- D
Drop of 6" -Time
11Iz0
Mins.lst 3"Dro
Mins . 2nd 3"Drop
19
Notes & Sketches on Back Frank C. Gelinas & Associates, North And.
L
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N
s
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S
GRA
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