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Miscellaneous - 72 SUGARCANE LANE 4/30/2018 (2)
i N V IV cnG r G) C.) > co N D 4 m G Z G T i d +3, Air_ arm Rr' rM, N c r� 1 � ✓ '+�'�S,y '"l xxr��'� ' < :"� � x iL � � . ��� t y k4 °drit-a-�`+ aaij'1 4'"'i';:�- .�• UM r� ey �" :.�. � �* "' r . •'� �-3� ,✓ �F � fy Y�� xr�'*�Y.� n'.{�NH'Y4 �ti� a.Srr.A'` s- ��SYs`I, r ;. r bn + Et'.t rt v ♦?`t+,.s f �r -v - ° r• KN LOT"#:% ; d N�1,4pV i9yL , syr} z: ✓ _>i'` A 't.:n.# �r 5 1 1 .. Y ' �?C�,r� • a ° 'i� `� UJ_ s. PARCEL#'�k F >5 .. G, STREET t'`} /'+n QTS (��'TnN PE j l✓v t�' MCn f'S�c� F i'is •r}'�'p j •r�✓2..7"2- z . ,� i. Sd�!�1'„a�� 1\�� L!�lf{i].LR L�LOW-11. s a x AS KLAN REVIEW .FEE BEEN PAID? ES i NO T ,�. + "" +P Fe, Y J r�vl-t-a-.4 r� z.,x t � t,�� v x ,. d _ .} f • '. I { ..4 ✓'") -CYC+, t r..2?+s'� f ✓ hl ' + t°' r ;, PLAN ARRROVAL: �„� t R DATE r APP. BY i`i�'. e.�."r�.� �+c bx }l �.{r. :%> y� 4'f } 4 }k PLAN DATE.. �d t 0.a Fl, f' f.:1f •• .e 3 f ?' iF < 1 ,� Y \ � r 5 � }T _ ' CONDITIONS ✓ s ,,: ° >� __ t 'I ,s Nr �•. S kx rL L iv, r .-l' ` �,}E�:v 2�' �',x j`� .r JCR i�sl {�-LY.r.� rJ��',�,'h? �L �ik... �r.Y,'�?,-,tF�J.��� _�•::`-� �.' _s;, l.t .., i s;.: -. 1 f r ym rWATER SURPLY:` }r TOWN zf=3 WELL � 1 1 �kix'. WELL PERMIT i ' DRILLER 1 1,psl+c s l y + r t 3 c ✓,= -,�. , °WELL TESTS: ` t 7.t; r HEMICAL ,; DATE APPROVED IA I DATE APPROVED " BACTERIA I DATE APPROVED COMMENTS i � 1 I 4 � ' 1 FORM U APPROVAL: - APPROVAL TO ISSUE ' NO _JQX ° .DATE I SSUED t r BY -- If CONDITIONS: s i ,FINAL APPROVALa4,. ALLOPERMITS PAID '. a YES NO } WELL.'CONSTRUCTION APPROVAL YES NO SEPTIC .SYSTEM CONSTRUCTION APPROVAL NO NO �f OTHER YES NO ANY,'VARIANCE NEEDED YES NO FINAL BOARD OF HEALTH APPROVAL: DA TE.�� BY:�_ `.I lye rr , �y::., - 'Y t r { .G..f L .. q.. t` ,-� z Y 'k"k�l�i �r r+n� 3 at, v+ 'ttL t� Y t} Z_ s k : 4 u 1 3. tt� m $ rr < W yx - xt r ft t-3;. �.+` J• {f{t�4krt�'. pik.`t?>•r`jt.°A%,; %�.i!"1`;7:`.i' 't Y,;`n p rst;,{;.1, !+� .t I},\k�tyv.a .;-.. .�'6?;#'i.' {a. r`>-; 1, a.'k. :. f n11 t .`4�t'+ x,5 { _� F y . i.; °�s 4$ L Y �iM \ � ¢ �iry s.r..yX a'� q a •fr + f a ' ¢ t y .4.= ' r � r < } ' I.•�:. + �' '�!`,a��t •i;.4 Idy,,,,1W, �.:�3,1�6" ,5id•�^;;''}4t ��it*w�� L -a<,'-! �'y"'o, ,ut."y:��y��� � q'�F � �1xPi Y41;.'�f� '.f .iys �� � yt �. "�., �:�,q{ ,.t+, a'., ... t . 4 .s �z� t S 'axy M i ss ,.t t p 4 ti. Fi + : �, x „� Car y_� p •s } _. •f 6.3 1>, b+ _ ; y 1.s t a I s rkt kxr a� i�i Iaapaa ri;� air 't� (F k # 3}y£;Eki z a , S c, rA F 31y}.i. 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'S7 ^r- ,''. ,ry �, !q 4.j . .r 1 `� t•,r iy W 3' t xY f ] 1 XS 11 JEq':INSTALLER LICENSED? � ,s, �i{"Iok. �tq r �� .,,YES �"t ; . , NO; r$: - i c•.' ]. j�: .may,,, 4 ;'' ? ��, - "# "� �-"` .:,%7r x# ;� .q'. �, :0 '},�+7 ; !;'�L§'} ': ':r'4 fi h, r;5 Yt r".•;itn+£n . t - 5', 1 ir,` , it $ t-". � C Ts'q �' � ,}'fS+ - r {.'i . ;" ' + 4 F kJ? ''$, K 'fA. s'rz.«t�,ikidr];,t ,�g( .Ing i s 9 v4-qi.' �'K' �ySHt;s"3�t e4wft i, �. 4.. p%3:w'3 r -y,. �+c t..k]+qs! a-' �'. _ ,.,y. �.n y +'f : - q - c�e Fr ;t� y{.. �.-#M_+ ut E�•a r, ,�yit�•.c.<'y' t 1' .,t1..t '} �Y` .yr v ? 5 i' v t , s k'' rs .•r c :.y ,. r;� w > v tx .-i 7;r t r )t '.i -i �ti�3 t .H_ f a-. jl 7�afi,; sF e. Sy�3 « w t txriFTYPE OF CONSTRUCTION• �'�, 14i 4~x ' 2 aJ�, „V._+ REPAIR q: 1. �p td c- f'�kgs{��, �1+� °°}}���4\1lx�f �`J.j �+. GZi•*'N.X f fi •�6iri t `s - 1 4,}:a rJb �.. '.t 1 i• + '' q a,j, t NC 3, aF f ` - "'sd'k f .iC� r-+` i' phi j r ._ }3?; aA ._, 1� tr ., rt" „ ' I 11"r ' i ..7 -�'k .; -•� _, ., 31. 7 >:..-yr r r f•a•- y, t1t {' _z .NCW CONSTRUC? ION: :Zpr CERTIFIED PLOT, PLAN. -REVIEW fr. EYES - ' :ND f" _ dt4 / c� t 'Iv t 3 >5`t + ' IS(�k�� $�:,2.A}�r,'u.t�', , �.t'%<< "its°',.-CONDIT_ IONS. OF APPROVAL S _$" ".�.}� .YES `- NO <W;, L Ns s �a4df r; fj84 x ' >r '` � n �r r > � r � s ' P� f„ ( FROM . FORM U) � � . a a�;�a�: � � ` X t � - r �, t, � i. v-:. I .I r {¢J ca rF r sT , Lt s a , rt. 4 r �Z. aSY •''+F 2r Y.'iE { Y� Cf .+{R(i i, Kk t\C 3 f;. rf '�j/ ,4 ti,il ,>, ` ?{ < r Fv .: t aYii ,Y11�. 4 D JQ ';yyt \::t,:. } , tr•Y v r 7.i. '" 4 4:. }.,i, { } ` `5 1. �i t.- r s t�" +iILJ 1 M: t= al. i; -i �, Sq.; . « 1 f r i �'C � �K < k r . t t _rVlr f < r ft .�.f„ `�' ; � ?.d : r +' 4.} �` � `-ISSUANCE OF 'DWC •PERMIT 'f ?}; ;, fes t'r�',t �?4.. - YES NO l v "t ,n 7 �,„rrs 'iAt`'r�'ty(3 y hr x -r re ,,r Sat i.'$ ,, ,,,� a t,. 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Y ,.'>, r. •, u , I L ++E f *fit11 I _�l,�`�EXCAVATION INSPECTION: l r _tn,�;`, NEEDED: ' "I I. q f 4 ft nt $mow& -}'i tet' �=if a!]tjg'r+z:,,5`,. �.;-r?''.k z }rtY'.tto-ft ti �$: 3 i t �,tr:ne tl. +'�. 4 t a: �t rt �... . r 4 �` f- -c-,, Ar R'. .>? :a.£ :'°� tr F ' ti: n'a '"- ` s+' n'ix t U?' .i f l .f L .r b�+ a. y 'a•., t, i f �` r 4 t ,' . `,.... + ^r C \ r.,,r 9 iiysi� �, �, 1 r`y 1t+i 5 er .i+ •F G ', 1 4 r d - ax -, {, t k iY' - at• . to .. 'a 4 Yf r� i , c tfr� a3 Aly y t by t c1. t k + z, _ t ` t�1 ! `xs $ +LS'h `+ '�7 .n4•L�ftky�' f,. f 's' �,'h asc yv�t s } rf t } 1.. i Y �� ,t - + tt�A; t a:, a \.M -i 3 it; „t 4 4 '+^a sr i, t .d:. Y..f;•{tM1 l� :..,� K v Y ;_s t z{ay. ..5 .tom ! 1 r / 21:t :% i..\ �, . 1 q c A `5' ply fi. "si y ,x : s �s r r, - sz. i I J t \'_: { "k Ir •t a ` w t } ] r.,�Ar xt a'r r3 -1, 1, '4 �y . �,Yj F4 `a {,a r r. - 41 - r, A • w 1:. 1 t_ t e .". r r�et`.r : KS M%' 'st• F r av: `- E w. 4 ,r+ t s .1 3f - 3i a.n y '( :t -� {�'$A >r�3 tF its 2 + Fr as F J .h H. ` ' . ,�! ,l i f 'ri £ t '�•i5 1T `'� _.,,. {•+�dj Yv, 1. <. - i )' F - !t, r >i r, t� s .r z .4 e' E y . f f ti S '� ...-,. '3a4 .} \ 3 Qh iP' . 3.,' P t rc.fi PASSED �fJHY 1 h .f fir`-Y�tf�L M'K t t: ' `�'•` s&; .v- , r. t y , •.a'•<ti w „ } i.:, , :C ` • - • .y a .:F y t „, 'f•4&r'�CONSTRUCTION INSPECTIONS NEEDED: 141 .1 '°i T yrrsxt # x,r ,�5 s K4- _ r iCk�yq^ t� r ,r" � r' +.:.t 't S r t .� t1 .. tt, N 1. 1. 1 .4 t Is ,+} ;£ 1 41 b m7 ` t. , Y 1 1 J,- �., q { C'. jf + \1s Lt +cZ .l �Y r at { is ?s^ r " a,. z 3 'r, F '\ { '� � 'yre^'' t - i " ..;5 '%. t r / ,�"j r -/.J. ' 7-•�-- /(�+2..,�� Y _ i t �c / t" r t} a % �/ V :/ CJ � �6©� d / / /11 / /AS 7 t I.!'' a'S, 6� `'fit trk'. ]� f '1 L bi.4 =?,?i } 4L F I ,£.:s. VZ<s - -r 3 r +'il rt < :. r t '.- 41 � l'-. ,. r b �. rt ! .. , ,, z t tR 4{.. _ r i} s t 4 , ice,.. r - '*+ , .1 Iyjj 1'' • " Yui t i£"�`'t F' d`{�� .�,,�j�,a.-.�n` % + r, ,r,..3•r''':;.., 1..� . ` a t. o r >< :i`.. k; - f t . !' t `F. rr W Yi (x A� xrii4yk k+ e ,.w 7 t`�f•f i< j ...',i f 3 4 ";. ., : il- t - -1 x S t•: i-' } j q . 1 ' r x•� AS BUILT PLAN SATISFACTORY : YES ' ' r� ' ... 1%i, i .3}E4 S ,yy- 2 c'tti S r f� �� � Y ` .�.i[ f _{ M .`. � . I..'�'-a v 1..'. �' J i t F Y E• -F' " a 9.it S % a r �• t L T. 1i. r t ... .. 3 l ,( r �' r i $ , ,, , • t t.. , �'t a :art : !. �. 7 t -. !._. , , . , ., y 5 ::' - � . APRROVAL TO BACKFILL: DATE: BY 4 t ° `.1 t U,"' S %r'.,zi� , R �� r t ,t ,`. ti S. F i, .. a i ".. ': - . , i'•. '; 1.e` FINAL,GRADING APPROVAL:.:4DATE BY t.il� ,, .ti T z,! Yy 3 d '2 .. S - 1 } f - I. .. i.,.. a yi t. �t1 1f . ^. r a : ;a tx�.: xfs.-�111 i ,1 s ,. - , ;FINAL CONSTRUCTION •APPROVAL: DATE: Z2 j BY^11 I: f) 44 .4' it: �; r;, tri : n ... ; .- Fir . t h r :' _ ' y _ t. % t +I t + ,2 &r a� - a r, . 34 it i>L t ; l i r".` . TT n fr { I' I J, I a s't�. rti,,ls r,l q 9 { C ,� a' 4_ s ` r' 4 t 1. t t Il } s z r ] b `�\ , 'i 4'. = f j4 �t tir Y t 1 to �F r S: f (- .i y a 1 s tiit%.'tii 'r1' "%'..".. `., r . tiR r s + 4 t,. Y"f c+ ,r a .' S 1 y 'F _ C :1,$� t- 'lklk F _ tJtr v , 4] i:i - s.. l r of FC S Srsit } �t : a s i r x: t r h 4 % ;; t [h S fi 1 5$ �'" , va acl . , I. h 1.i t I �'r t` r k..•' '4i, i Y i �r2, krA s - 7 t tgrz,. z J ash n£ 'i. 4� 5 4+a I 1- s r Se Y }1 r i i __ ". f f t4 Y if A k ) r .} _ 7 f ; " t t .. 4 r �D F.. r .;,, f 4 , i.Y y V. J. 4 �,h, .�� r 'S1' U :4. .Yt �.�. 1. - ] ..r. 1 c , t . . i ,, 4 ti. . . . ._ j ... .,. - . ... _ .. _ _ •'4 107 FOREST STREET MIDDLETON, MA 01949 (978)774-7122 FILE # 91100A f' . . . . . . . . . . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNER'S NAME: DUDMAN PROPERTY ADDRESS: 72 SUGARCAN LANE; N. ANDOVER; MA ADDRESS OF OWNER: SAME (IF DIFFERENT) DATE OF INSPECTION: SEPTEMBER 11, 2000 NAME OF INSPECTOR: THOMAS CHIGAS * THE PROFESSIONAL EXPERTS IN THE SEPTIC AND DRAIN INDUSTRY 107 FOREST STREET MIDDLETON, MA 01949 (978)774-7122 _ t; L l _11� Il"", FILE # 91100A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION PROPERTY ADDRESS:72 SUGARCANE LANE NAME OF OWNER: DUDMAN NORTH ANDOVER, MA ADDRESS OF OWNER: SAME DATE OF INSPECTION: SEPTEMBER 11.2000 NAME OF INSPECTOR: (PLEASE PRINT) THOMAS CHIGAS I AM A DEP APPROVED INSPECTOR PURSUANT TO SECTION 15.340 OF TITLE 5 (3 10 CMR 15.000) COMPANY NAME: CURRIER ENVIRONMENTAL SOLUTIONS. CORP. MAILING ADDRESS: 107 FOREST STREET. MIDDLETON. MA 01949 TELEPHONE NUMBER: (978) 774-7122 CERTIFICATION STATEMENT I CERTIFY THAT I HAVE 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 PREFORMED BASED ON MY TRAINING AND EXPERIENCE IN THE PROPER FUNCTION AND MAINTENANCE OF ON-SITE SEWAGE DISPOSAL SYSTEM. THE SYSTEM: YES PASSES CONDITIONALLY PASSES NEEDS FURTHER EVALUATION BY THE LOCAL APPROVING AUTHORITY FAILS INSPECTOR'S SIGNATURE: /Ael S DATE: SEPTEMBER 11.2000 THE SYSTEM INSPECTOR SHALL SUBMIT A COPY OF THIKfNSPECTION REPORT TO THE APPROVING AUTHORITY (BOARD OF HEALTH OR DEP) WITHIN THIRTY (30) DAYS OF COMPLETING THIS INSPECTION. IF THE SYSTEM IS A SHARED SYSTEM OR HAS A DESIGN FLOW OF 10,000 GALLON 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. NOTES AND COMMENTS: N/A REVISED 9/2/98 PAGE 1 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 INSPECTION SUMMARY: CHECK AO B, C, OR D: A. SYSTEM PASSES: YES I HAVE NOT FOUND ANY INFORMATION, WHICH INDICATES THAT ANY OF THE FAILURE CONDITIONS DESCRIBED IN 310 CMR 15.303 EXIST. ANY FAILURE CRITERIA NOT EVALUATED ARE INDICATED BELOW. COMMENTS: B. SYSTEM CONDITIONALLY PASSES: N 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. INDICATE YES, NO, OR NOT DETERMINED (Y, N, OR ND). DESCRIBE BASIS OF DETERMINATION IN ALL INSTANCES. IF "NOT DETERMINED", EXPLAIN WHY NOT. N THE SEPTIC TANK IS METAL, UNLESS THE OWNER OR OPERATOR HAS PROVIDED THE SYSTEM INSPECTOR WITH A COPY OF A CERTIFICATE OF COMPLIANCE (ATTACHED) INDICATING THAT THE TANK WAS INSTALLED WITHIN TWENTY (20) YEARS PRIOR TO THE DATE OF THE INSPECTION; OR THE SEPTIC TANK, WHETHER OR NOT METAL, IS CRACKED, STRUCTURALLY UNSOUND, SHOWS SUBSTANTIAL INFILTRATION OR EXFILTRATION, OR TANK FAILURE IS IMMINENT. THE SYSTEM WILL PASS INSPECTION IF THE EXISTING SEPTIC TANK IS REPLACED WITH A COMPLYING SEPTIC TANK AS APPROVED BY THE BOARD OF HEALTH. N 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). N BROKEN PIPE (S) ARE REPLACED N OBSTRUCTION IS REMOVED N DISTRIBUTION BOX IS LEVELED OR REPLACED N 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): N BROKEN PIPE (S) ARE REPLACED N OBSTRUCTION IS REMOVED REVISED 9/2/98 PAGE 2 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11, 2000 C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: N CONDITIONS EXIST WHICH REQUIRE FURTHER EVALUATION BY THE BOARD OF HEALTH IN ORDER TO DETERMINE IF THE SYSTEM IS FAILING TO PROTECT THE PUBLIC HEALTH, SAFETY AND THE ENVIRONMENT. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(B) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: N/A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF SURFACE WATER N/A 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 AND SAFETY AND THE ENVIRONMENT: N 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. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN A ZONE I OF PUBLIC WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N THE SYSTEM HAS A SEPTIC TANK AND SOIL ABSORPTION SYSTEM AND THE SAS IS LESS THAN 100 FEET BUT 50 FEET 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. METHOD USED TO DETERMINED DISTANCE (APPROXIMATION NOT VALID). 3) OTHER: N/A REVISED 9/2/98 PAGE 3 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 D. SYSTEM FAILS: YOU MUST INDICATE EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING: N I HAVE DETERMINED THAT ONE OR MORE OF THE FOLLOWING FAILURE CONDITIONS EXIST AS DESCRIBED IN 310 CMR 15.303. THE BASIS FOR THIS DETERMINATION IS IDENTIFIED BELOW. THE BOARD OF HEALTH SHOULD BE CONTRACTED TO DETERMINE WHAT WILL BE NECESSARY TO CORRECT THE FAILURE. YES NO N BACKUP OF SEWAGE INTO FACILITY OR SYSTEM COMPONENT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N DISCHARGE OR PONDING OF EFFLUENT TO THE SURFACE OF THE GROUND OR SURFACE WATERS DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N STATIC LIQUID LEVEL IN THE DISTRIBUTION BOX ABOVE OUTLET INVERT DUE TO AN OVERLOADED OR CLOGGED SAS OR CESSPOOL. N/A LIQUID DEPTH IN CESSPOOL IS LESS THAN 6' BELOW INVERT OR AVAILABLE VOLUME IS LESS THAN '/z 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 N ANY PORTION OF THE SOIL ABSORPTION SYSTEM, CESSPOOL OR PRIVY IS BELOW THE HIGH GROUNDWATER ELEVATION. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 100 FEET OF A SURFACE WATER SUPPLY OR TRIBUTARY TO A SURFACE WATER SUPPLY. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN A ZONE I OF A PUBLIC WELL. N/A ANY PORTION OF A CESSPOOL OR PRIVY IS WITHIN 50 FEET OF A PRIVATE WATER SUPPLY WELL. N/A 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. LARGE SYSTEM FAILS: YOU MUST INDIQATES EITHER "YES" OR "NO" TO EACH OF THE FOLLOWING: THE FOLLO G CRITERIA APPLY TO LARGE SYSTEMS IN ADDITION TO THE CRITE BOVE: THE SYSTEM SERVES A ILITY WITH A DESIGN FLOW OF 10,000 GPD O ATER (LARGE SYSTEM) AND THE SYSTEM IS A SIGNIFICANT AT TO PUBLIC HEALTH ANDS AND THE ENVIRONMENT BECAUSE ONE OR MORE OF THE FOLLOW ONDITIONS EXIST: YES NO THE SYSTEM IS WITHIN 400 FEET WATER SUPPLY THE SYSTEM IS WITHIN 200 OF A TRIBUTARY TO URFACE DRINKING WATER SUPPLY THE SYSTEM IS LOCAIN A NITROGEN SENSITIVE AREA RIM WELLHEAD PROTECTION AREA-IWPA) OR A MAP ZONE II OF A PUBLIC WATER SUPPLY WELL THE OWNER OR OP TOR OF ANY SUCH SYSTEM SHALL UPGRADE THE SYSTEM IN ACCO CE WITH 310 CMR 15.304(2)-PnASE CONSULT THE LOCAL REGIONAL OFFICE OF THE DEPARTMENT FOR FURTHER --- REVISED 9/2/98 PAGE 4 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 CHECK IF THE FOLLOWING HAVE BEEN DONE: YOU MUST INDICATE EITHER "YES" OR "NO" AS TO EACH OF THE FOLLOWING: YES NO Y PUMPING INFORMATION WAS PROVIDED BY THE OWNER, OCCUPANT, OR BOARD OF HEALTH. Y NONE ON 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. Y AS BUILT 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. THE SIZE AND LOCATION OF THE SOIL ABSORPTION SYSTEM ON THE SITE HAS BEEN DETERMINED BASED ON: Y EXISTING INFORMATION. FOR EXAMPLE, PLAN AT B.O.H. Y DETERMINED IN THE FIELD (IF ANY OF THE FAILURE CRITERIA RELATED TO PART C IS AT ISSUE, APPROXIMATION OF DISTANCE IS UNACCEPTABLE) [15.302(3)(b)] Y THE FACILITY OWNER (AND OCCUPANTS, IF DIFFERENT FROM OWNER) WERE PROVIDED WITH INFORMATION ON THE PROPER MAINTENANCE OF SUBSURFACE DISPOSAL SYSTEMS. REVISED 9/2/98 PAGE 5 OF 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 SYSTEM INFORMATION FLOW CONDITIONS RESIDENTIAL: DESIGN FLOW: 440 G.P.D./BEDROOM. NUMBER OF BEDROOMS (DESIGN): 4 NUMBER OF BEDROOMS (ACTUAL): 4 TOTAL DESIGN FLOW: 440 NUMBER OF CURRENT RESIDENTS: 3 GARBAGE GRINDER (YES OR NO): NO LAUNDRY (SEPARATE SYSTEM) (YES OR NO): YES; IF YES, SEPARATE INSPECTION REQUIRED LAUNDRY SYSTEM INSPECTED (YES OR NO): N/A SEASONAL USE (YES OR NO): NO WATER METER READINGS, IF AVAILABLE (LAST TWO YEAR'S USAGE (GPD): 322'388 GALS FOR TWO YRS USAGE. SUMP PUMP (YES OR NO): NO LAST DATE OF OCCUPANCY: CURRENT TYPE OF LISHMENT: DESIGN FLOW: ---CD (BASED ON 15.203) BASIS OF DESIGN FLOW: GREASE TRAP PRESENT (YES OR N INDUSTRIAL WASTE HOLDING TANK PRESE SOR NO): NON -SANITARY WASTE DISCHARGED TO THE TITLE (YES OR NO): WATER METER READINGS, IF AVAILABLE: LAST DATE OF OCCUPANCY: OTHER (DESCRIBE LAST DA CCUPANCY: GENERAL INFORMATION PUMPING RECORDS AND SOURCE OF INFORMATION: SYSTEM PUMPED AS PART OF INSPECTION (YES OR NO): NO IF YES, VOLUME PUMPED: N/A GALLONS REASON FOR PUMPING: LAST PUMP SUMMER 1999 TYPE OF SYSTEM YES SEPTIC TANK/DISTRIBUTION BOX/SOIL ABSORPTION SYSTEM N SINGLE CESSPOOL N OVERFLOW CESSPOOL N PRIVY N SHARED SYSTEM (YES OR NO) (IF YES, ATTACH PREVIOUS INSPECTION RECORDS, IF ANY) N UA TECHNOLOGY ETC. ATTACH COPY OF UP TO DATE OPERATION AND MAINTENANCE CONTRACT TIGHT TANK COPY OF DEP APPROVAL OTHER: N/A APPROXIMATE AGE OF ALL COMPONENTS, DATE INSTALLED (IF KNOWN) AND SOURCE OF INFORMATION: INSTALLED 7 YEARS AGO, OWNER SEWAGE ODORS DETECTED WHEN ARRIVING AT THE SITE (YES OR NO): NO REVISED 9/2/98 PAGE 6 OF 11 SUBSURFACE SEWAGE DISPOSAL INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 BUILDING SEWER: (LOCATE ON THE SITE PLAN) DEPTH BELOW GRADE: 4'6" MATERIAL OF CONSTRUCTION: CAST IRON YES 40 PVC OTHER (EXPLAIN) DISTANCE FROM PRIVATE WATER SUPPLY WELL OR SUCTION LINE: N/A DIAMETER: 4" COMMENTS: (CONDITION OF JOINTS, VENTING, EVIDENCE OF LEAKAGE, ETC.) NO SIGNS OF LEAKAGE IN OR OUT, SOILS ARE CLEAN AND DRY. SEPTIC TANK: YES (LOCATE ON SITE PLAN) DEPTH BELOW GRADE: 29" MATERIAL OF CONSTRUCTIOMYESCONCRETE METAL FIBERGLASS POLYETHYLENE OTHER (EXPLAIN): IF TANK IS METAL, LIST AGE IS AGE CONFIRMED BY CERTIFICATE OF COMPLIANCE (YES/NO) DIMENSIONS: 101 X 5'W X 5'H OUTLET INVERT @ 4'4" = 1500 GAL SLUDGE DEPTH: 8" DISTANCE FROM TOP OF SLUDGE TO BOTTOM OF OUTLET TEE OR BAFFLE: 26" SCUM THICKNESS: <1" DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET TEE OR BAFFLE: 18" DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF OUTLET TEE OR BAFFLE: 9" HOW DIMENSIONS WERE DETERMINED: SLUDGE JUDGE, ROD, RULER COMMENTS: (RECOMMENDATION FOR PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, DEPTH OF LIQUID LEVEL IN RELATION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE, ETC.) THE INLET AND OUTLET TEE'S ARE CEMENT CONSTRUCTION AND INTACT. NO SIGNS OF LEAKAGE IN OR OUT. THE LIOUID LEVEL IS @ NORMAL HIGHT. THERE'S NO SIGNS FAILURE IN OR AROUND AREA, SOILS ARE CLEAN AND DRY. GREASE TRAP: NO (tOC4TE ON SITE PLAN) DEPTH BELOW'GRADE: MATERIAL OF CONST ON: CONCRETE METAL FIBERGLASS POLYET E OTH (EXPLAIN) DIMENSIONS: SCUM THICKNESS: DISTANCE FROM TOP OF SCUM TO TOP OF OUTLET T E: DISTANCE FROM BOTTOM OF SCUM TO BOTTOM OF ET OR BAFFLE: DATE OF LAST PUMPING: COMMENTS: (RECOMMENDATIO PUMPING, CONDITION OF INLET AND OUTLET TEES OR BAFFLES, OF LIQUID LEVEL IN R LATION TO OUTLET INVERT, STRUCTURAL INTEGRITY, EVIDENCE OF LEAKAGE, ETC.) REVISED 9/2/98 PAGE 7 OF 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 GHT OR HOLDING TANK: (TANK MUST BE PUMPED PRIOR TO, OR AT TIME OF, IN TION) (LO ON SITE PLAN) DEPTH BELOW E: MATERIAL OF CONSTR N: CONCRETE METAL F IIBB EVKASS POLYETHYLENE OTHER (EXPLAIN) DIMENSIONS: CAPACITY: GALLONS DESIGN FLOW: GALLONS/DAY ALARM PRESENT: / ALARM LEVEL: AL WORKING ORDER: YES DATE OF PREVIOUS P ING: COMMENTS: INLET TEE, CONDITION OF ALARM AND FLOAT SWITCHES, ETC.) DISTRIBUTION BOX: YES (LOCATE ON SITE PLAN) DEPTH OF LIQUID LEVEL ABOVE OUTLET INVERT: 0" DEPTH BELOW GRADE: 5' COMMENTS: (NOTE IF LEVEL AND DISTRIBUTION IS EQUAL, EVIDENCE OF SOLIDS CARRYOVER, EVIDENCE OF LEAKAGE INTO OR OUT OF BOX, ETC.) THERE'S EOUAL DISTRIBUTION AND THE BOX IS LEVEL. NO SIGNS OF LEAKAGE IN OR AROUND AREA. THERE IS ONE INLET AND TWO OUTLETS SCH 40 PVC CONSTRUCTION. THE SOILS ARE CLEAN AND DRY.THE DIMENSIONS ARE 18" X 18" AND IN GOOD CONDITION. PUMPS IN WORKING ORD OR NO): ALARMS IN WORKING ORDER (YES COMMENTS: (NOTE CONDITIONS OF PUMP CHAMBER, CONDITI REVISED 9/2/98 PAGE 8 OF 11 AND APPURTENANCES, ETC.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11, 2000 SOIL ABSORPTION SYSTEM (SAS): YES (LOCATE ON SITE PLAN, IF POSSIBLE; EXCAVATION NOT REQUIRED, LOCATION MAY BE APPROXIMATED BY NON -INTRUSIVE METHODS) IF NOT LOCATED, EXPLAIN: TYPE: LEACHING PITS, NUMBER: LEACHING CHAMBERS, NUMBER: TWO 81 X 5'W X 3'H LEACH CHAMBERS LEACHING GALLERIES, NUMBER: LEACHING TRENCHES, NUMBER, LENGTH: LEACHING FIELDS, NUMBER, DIMENSIONS: OVERFLOW CESSPOOL, NUMBER: ALTERNATIVE SYSTEM: NAME OF TECHNOLOGY: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, DAMP SOIL, CONDITION OF VEGETATION, ETC.) THERE WAS A LIQUID LEVEL OF 12" IN CHAMBER.24" OF STORAGE SPACE.THERE WAS NO SIGNS OF HIGH STATIC LEVEL OR FAILURE. SOILS AND STONE ARE CLEAN AND DRY. THERE'S NO SIGNS OF WETLANDS VEGETATION IN OR NEAR SAS. L: NO IN SITE PLAN) NUMBER AND C GURATION: DEPTH -TOP OF LIQUID LET INVERT: DEPTH OF SOLID LAYER: DEPTH OF SCUM LAYER: DIMENSIONS OF CESSPOOL: MATERIALS OF CONSTRUCTION: INDICATION OF GROUNDWATER: INFLOW (CESSPOOL MUST BE PUMPED AS COMMENTS: (NOTE CONDITION OF (LOCATE SIGNS OF HYDRAULIC FAILURE, LEVEL OF PONDING, CONDITION MATERIALS OF CONSTRUCTION: _ DEPTH SOLIDS: COMMENTS: (NOTE CONDITION OF SOIL, SIGNS OF URE, LEVEL OF PONDING, REVISED 9/2/98 PAGE 9 OF 11 ATION, ETC.) ATION, ETC.) SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 SKETCH OF SEWAGE DISPOSAL SYSTEM: INCLUDE TIES TO AT LEAST TWO PERMANENT REFERENCE LANDMARKS OR BENCHMARKS LOCATE ALL WELLS WITHIN 100' (LOCATE WHERE PUBLIC WATER SUPPLY COMES INTO HOUSE) House A 1 p -3)ox O TQIcci 01- lr ' (i) Ccµ 2) FraNf Jam SUGARCONe- LAI REVISED 9/2/98 PAGE 10 OF 1 I ��egc�er A & T/ =3,3 B jo T 1 -377 „ A 4o -DI 8 �O �► =82'x„ �b C%1✓/ " cob a /&CNS = 89 �" CN I to Ctl2 ' `l , REVISED 9/2/98 PAGE 10 OF 1 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (CONTINUED) PROPERTY ADDRESS: 72 SUGARCANE LANE OWNER: DUDMAN DATE OF INSPECTION: SEPTEMBER 11.2000 NRCS REPORT NAME NO SOIL TYPE NO TYPICAL DEPTH TO GROUNDWATER NO USGS DATE WEBSITE VISITED OBSERVATION WELLS CHECKED GROUNDWATER DEPTH: SHALLOW N MODERATE DEEP SITE EXAM SLOPE SURFACE WATER CHECK CELLAR SHALLOW WELLS ESTIMATED DEPTH TO GROUNDWATER 8'+APPROX FEET PLEASE INDICATE ALL THE METHODS USED TO DETERMINE HIGH GROUNDWATER ELEVATION: Y OBTAINED FROM DESIGN PLANS ON RECORD Y OBSERVED SITE (ABUTTING PROPERTY, OBSERVATION HOLE, BASEMENT SUMP, ETC.) Y DETERMINED FROM LOCAL CONDITIONS N CHECKED WITH LOCAL BOARD OF HEALTH * CHECKED FEMA MAPS Y CHECKED PUMPING RECORDS N CHECKED LOCAL EXCAVATORS, INSTALLERS Y USED USGS DATA DESCRIBE HOW YOU ESTABLISHED THE HIGH GROUNDWATER ELEVATION. (MUST BE COMPLETED) THERE'S NO SUMP PUMP AND BASEMENT IS DRY.WHILE DIGGING IN YARD THERE WAS NO SIGNS OF WATER TABLE OR WETLAND VEGETATION IN OR AROUND SYSTEM.THERE'S NO ABBUTTING PROPERTY'S WELLS WITHIN 100'. NO SIGNS OF WATER ON PLANS. REVISED 9/2/98 PAGE 11 OF 11 ORM 1 RELEASE • _ INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. f APPLICANT Jnhn ( j cH n LOCATION: Assessor's Map Number SUBDIVISION PHONE` �-') ?,%U PARCEL a 3 I - LOT (S) STREET 5l tQQY` UIIL I n. ST. NUMBER _7 'C� **************OFFICIAL USE ONLY ********** CONSERVATION COMMENTS Z&(( TOWN AGENTS: TRATOR ids a r� tib 1n bur4r ao"e_ DATE APPROVED q`Mj( DATE REJECTED TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS FOOD INSPTOR-HEALTH DATE APPROVED DATE REJECTED DATE APPROVED DATE REJECTED COMMENTS,„�n`C PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE Revised 9197 jm i n 4c 77777, r N t it 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: 72 Sugar Cane Lane_ North Andover_ Owner's Name: _Linda Eaton _ Owner's Address: 72 Sugar Cane Lane_ _ North Andover, MA 01845_ Date of Inspection: _9/5/2003_ Name of Inspector: Neil J. Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 0�.� 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 ... N Further Evaluation by the Local Approving Authority F Inspector's Signature: Date: _9/5/2003_ The system inspector shall submit a copy o his inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ****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. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _72 Sugar Cane Lane- - North Andover — Owner: _Eaton_ Date of Inspection: _9/5/2003_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: _X 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. Answer yes, no or not determined (Y,N,ND) in the 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. ND explain: 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 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: Page 3 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 Sugar Cane Lane- - North Andover— Owner: _Eaton_ Date of Inspection: _9/5/2003 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 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 _ _ "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. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 72 Sugar Cane Lane _ _ North Andover_ Owner: _Eaton _ Date of Inspection: _9/5/2003 D. System Failure Criteria applicable to all systems: You must indicate "yes" or `nd'to each of the following for all inspections: Yes No _ _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool No Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool _ No Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. No Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. _ _No Any portion of a cesspool or privy is within 50 feet of a private water supply well. _ No 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.] No (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. 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. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: 72 Sugar Cane Lane— . North Andover— Owner: _Eaton_ Date of Inspection: 9/5/2003_ Check if the following have. leen done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks ? Yes _ Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes _ Was the facility or dwelling inspected for signs of sewage back up ? Yes — Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ Was 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: Yes no _Yes_ _ Existing information. _No_ 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 15302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 72 Sugar Cane Lane_ _ North Andover— Owner: _Eaton_ Date of Inspection: _9/5/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4Number of bedrooms (actual): _4_ DESIGN flow based on 310 CMR_ 15.203 (for example: 110 gpd x # of bedrooms): _660_ Number of current residents: _4 Does residence have a garbage grinder (yes or no): No Is laundry on a separate sewage system (yes or no): _ No Laundry system inspected (yes or no): Seasonal use: (yes or no): No_ Water meter readings: Yes_ Sump pumps (yes or no): _No_ Last date of occupancy: _Current COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgtt,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: _ Pumped 2 years ago, owner_ Was system pumped as part of the inspection (yes or no): _Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank Reason for pumping: _ Inspect tank & tees_ TYPE OF SYSTEM _X 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): _ Approximate age of all components, date installed (if known) and source of information: _10 years old, 4/3/1993, As built plan _ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Sugar Cane Lane- - North Andover— Owner: _Eaton_ Date of Inspection: _9/5/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: _4211 _ Materials of construction: _ _cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall to septic tank. 4" PVC in house, no leaks. SEPTIC TANK: X locate on site plan) Depth below grade: 30"_ Material of construction: _X_concrete _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: _10'z 5' x 4' Sludge depth: _7"_ Distance from top of sludge to bottom of outlet tee or baffle: 20"_ Scum thickness: _12" Distance from top of scum to top of outlet tee or baffle: _8" Distance from bottom of scum to bottom of outlet tee or baffle: _17"_ How were dimensions determined: _Difference in sludge & scum depth to tee length _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. _ 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.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Sugar Cane Lane— North Andover— Owner: _Eaton_ Date of Inspection: 9/5/2003_ 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/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: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0 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.): _D -box level & distribution equal. No evidence of leakage._ PUMP CHAMBER: (locate on site plan) Pump 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.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Sugar Cane Lane- - North Andover_ Owner: _Eaton_ Date of Inspection: _9/5/2003_ SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type X leaching pits, number: _2` leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching 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.): _Soil ok. Vegetation ok. No sign of ponding to surface. Camera inside of pits thru outlet in d -box. Pit #1, liquid 8" from invert. Pit # 2, liquid 12" from invert. _ 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 or no): 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.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Sugar Cane Lane _ _ North Andover_ Owner• , Eaton_ Date of Inspection: _9/5/2003_ 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. A to Tank = 33' A to D -Boz = 67'4" B to Tank = B to D -Boz Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 72 Sugar Cane Lane _ _ North Andover— Owner: _Eaton_ Date of Inspection: _9/5/2003_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 Feet Please indicate (check) all methods used to determine the high ground water elevation: X_ Obtained from system design plans on record - If checked, date of design plan reviewed: _4/3/1993_ 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 established the high ground water elevation: As per test pit data on design plan._ Sep 09 03 O3:47p N N cQY � S Q O J ¢ t - Q H N W ©0avva©vaLALALALAOfM1P%NP%. 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Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 72 Sugar Cane Lane, North Andover Owner: Eaton Date of Inspection: 9/5/2003 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. Neil J. Bateson Bateson Enterprises, Inc. FORM 4 - SYSTEM PUMPING RECORD C URRI R SEPTIC & DRAIN SERVICE. 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 COMMONWEALTH OF MASSACHUSETTS vo" AeAl'� , MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: �U �e/ 77,rl,o s�y�«� Ile" 47. SYSTEM LOCATION: Uri-c:Zeol- eP,//' DATE OF PUMPING: _ 5` .QUANTITY PUMPED: /SCJ GALLONS CESSPOOL: NO F__1 YES 0 SEPTIC TANK: NO 0 YES ®---' SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: 11 Sz DATE: ..� ' -� �� INSPECTOR:�j ��� Toi vi4 DF NORTH ANDOd''R/ BOARD OF HEALTH l JUN 1 01999 d4hk- ON r. cd LU z' o z °O a% c r O N.1 it o M � � f� � Q J Cld moGw.W W y = �' o 6o � aE N Z; . 4.v �.C2 L �l N �C V .73 m� cc tat N C p r_1 i EN U m •O it JN7 CD o o -y O.(.� r. m ✓!: 0 cm �Jll CD 0 VA 'WA ._ 'E V •tAO N•'Z o S: o m `cmc o W _ m C.'�" N IWi. coo r.+ R m w o 10� =� »-233 cc o CL= CLU ca `; o •N O O cm CJ o. o o a� = (A .C2 H �� C W W H s 0 . C. 4-m i Q. D CA co CO2 4� c O co Q _R CL CO3 O C.3 CO) C O Ca CZ Ca CD o, C o D � mm co �co o i o C- om Q � C O !d J -O O Co Z v Co Q. CO) C J Q z_ W a- } z z W Q > Q LU 0 0 r1 t o w x w wu a a Kj w cn -o ° M b a a x ' U w w o Q w z v v w° U) m w° g U x C2 w coo7n a w � v o co cn cn LU z' o z °O a% c r O N.1 it o M � � f� � Q J Cld moGw.W W y = �' o 6o � aE N Z; . 4.v �.C2 L �l N �C V .73 m� cc tat N C p r_1 i EN U m •O it JN7 CD o o -y O.(.� r. m ✓!: 0 cm �Jll CD 0 VA 'WA ._ 'E V •tAO N•'Z o S: o m `cmc o W _ m C.'�" N IWi. coo r.+ R m w o 10� =� »-233 cc o CL= CLU ca `; o •N O O cm CJ o. o o a� = (A .C2 H �� C W W H s 0 . C. 4-m i Q. D CA co CO2 4� c O co Q _R CL CO3 O C.3 CO) C O Ca CZ Ca CD o, C o D � mm co �co o i o C- om Q � C O !d J -O O Co Z v Co Q. CO) C J Q z_ W a- } z z W Q > Q LU 0 0 h 3,R 64N61-8-ST/G,c'�' House Tank IN Tank OUT D -box IN D -box OUT AS -BUILT CHECK LIST and FINAL INSPECTION Proposed Elevations /33.77 iia. 73 13g, 4E- / go /,3o' 36 Trench Inverts Line 1 1:3,0,66 Line 2 Line 3 Line 4 As -Built Elevation /3'7, 7q /37- 7S/ 13,3- 6-3 13a. )6 73,2 , 00 Bottom of Exc. pO Stone OK? D -box checked? L�Pipes cemented?z--� DATE r/No9 Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER ADDRESS ENGINEER 7—&6 1/E ADDRESS PLAN DATE Aon%/yz CONDITIONS OF APPROVAL: APPROVED DISAPPROVED PARCEL # oma► LOT # STREET REVISION DATE SUBSURFACE DISPOSAL DESIGN REVIEW FEE 4/0- PERMIT # DATE RECEIVED APPLICANT. 1-TAi✓Usz ASSESSOR'S MAP ADDRESS ENGINEER 7—&6 1/E ADDRESS PLAN DATE Aon%/yz CONDITIONS OF APPROVAL: APPROVED DISAPPROVED PARCEL # oma► LOT # STREET REVISION DATE 0 Town of North Andover, Massachusetts Form N0.2 MOR7�y ?ot..... +�o BOARD OF HEALTH 41 •_ 19_C a� DESIGN APPROVAL FOR sACIN4 - SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Applicant Test No.. Site Location T Reference Plans and Specs. ENGINEER DESIGN DATE Permission is granted for an individual soil absorption sewage disposal s s in accordance with regulations of Board of Health, Y tem to be installed CHAIRMAN, BOARD OF HEALTH Fee Site System Permit No._ aas� AMPAD NO. 23-176-400 SETS NO. 23-376-200 SETS TO DATEl TIME H (�a �!5^ FROM Ftit�EA C%�,�'ri�t � �1i37u1►�g "z �' OFW-- C) L OL; t : ' � ,:.uj fn to - -- SIGNED AMPAD NO. 23-176-400 SETS NO. 23-376-200 SETS Town of North Andover, Massachusetts Form No. 3 NORTH BOARD OF HEALTH 9 q-3 OL F p s i _ _ -_-e • ♦ off- .:.Q :�.-_ �)� • �• +,.:o.�""� DISPOSAL WORKS CONSTRUCTION PERMIT ,SSACMUSEt ApplicantY_J n2.t NAME ADDRESS �p TELEPHONE Site Location .-� a P ck1y---t - d�r��►'t �' - Permission is hereby granted to Construct (A or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 11 CHAIRMAN, BOARD OF HE�jLtH Fee D.W.C. No. G'Z� PLAN REVIEW CHECKLIST ADDRESS 3c2�'-✓ ��G/�'�'C�I/1�F 419 ENGINEER %- N&V,:!�- GENERAL 3 COPIES I/ CONTOURS (/ PERC INFO WETLANDS FDN DRAIN 1/ SEPTIC TANK MIN 1500G. 25' TO CELLAR D -BOX STAMP i/ LOCUS NORTH ARROW "-� SCALE PROFILE L/ SECTION BENCHMARK SOIL & ELEVATIONS WETS. DISCLAIMER WELLS & WATERSHED? %�D DRIVEWAY � Elev) WATER LINE c_- SCH40 ✓ TESTS CURRENT? .17 INVERT DROP GARB. GRINDER(+200% EDF) MANHOLE TO GRADE L,---- ELEV GW SIZE 7)Q-z� # LINES I,?' FIRST 2' LEVEL STATEMENT INLET 136,,` - OUTLET 430..b = , Zt3 (2" OR 17 FT) TEE REQ 'D? G,- S LEACHING RESERVE AREA (,'� 4' FROM PRIMARY? v"" 100' TO WETLANDS, -----",2% SLOPE 100' TO WELLS r/ 351.TO FND & INTRCPTR DRAINSL--' 4' TO S.H.GW'i•_--- 325' TO SURFACE H2O SUPP L- '- 4' PERM. SOIL BELOW FACILITY MIN 12" COVER FILL?(25' if above natural elev;.� !i low) BREAKOUT MET? ✓y TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/1001) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? BOT X LDNG + SIDE X LDNG = TOT (L x W x #) (G/ft2) (DxLx2x#) PITS MIN 660 LEACHING GW MIN 41 BELOW BOTTOM MANHOLE/PIT EXCAV 2x EFF W OR D 12"-48" STONE SURROUNDING BOT + SIDE x LOAD = TOTAL_ (L x W x #) (2 x (L+W) x D x #) CHAMBERS COVER >3 FT - VENT Q� �p(o0 �AGff �` � `f r CNran Xaa l s roNE ✓' SPG�I Sff �Gr 3lin sf�E / At, (Z X CLtW) xD x# FIELDS MIN 900 ft LEACHING PERC RATE FASTER THAN 20M/IN GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE? 4" PEA STONE? DIST LINE SLOPE .005? >3' COVER - VENT SCH 40 MIN 12" COVER L x W = T x LDNG > DESIGN FLOW? DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W W Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gpm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH TOWN OF P" ""� SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS DATE OF PUMPING: 9— '�-0-3 SYSTEM LOCATION (example: left front of house) (' & ( �- -! C�- -0 -J hk)se QUANTITY PUMPED: ( 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: 6' --C-\ Commonwealth of Massachusetts UCity/Town of NORTH ANDOVER MASSP& tiW System Pumping Record MAY 19 2009 Form 4 DEP has provided this form for use b local Boards of Health. T edSystM-p ft �c rd must be submitted to the Local hoard of Health or other approving aut Lo _L, t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms on the computer, use 6 i� (.•�P s!r' �'f` only the tab key to move your Address i d"y . �� � 1'� 1 � � �- •..c.. '� �,.:t �,���"� %� <� '(' cursor - do not use the return City/Town State Zip Code key. 2. System Owner: k x -\r �R Ks to f d Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record 4--A--, 1. Date of Pumping Date 2. Quantity Pumped: Gallons I Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No Ifes was it cleaned? Y El Yes ❑ No 5. Condition of System: 6 System Pumped By: Name Vehicle License Number Company a i iii 7. Location where contents were disposed: SigHauler"/ Date http://www.mass,gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Town of North Andover, Massachusetts Form No. 1 BOARD OF HEALTH 13 19 32J APPLICATION FOR SITE TESTING/INSPECTION Applic Site Lc Engineer �C(V\ �Q�-�, Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. 44 % 1 S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. Town of North Andover, Massachusetts BOARD OF HEALTH, Form No. 1 3a °h 19 7 o A i APPLICATION FOR SITE TESTING/INSPECTION TE �9SSACHUSE� , Applicant 1 � Jq r2y .�Yld t,,i.2 �S cl- 9 L11.-1 NAME V ADDRESS TELEPHONE Site Location Engineer Tri cnu�er Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No.