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Miscellaneous - 742 WINTER STREET 4/30/2018
N O N D z S 5� � rn AV (°- North Andover Board of Assessors Public Access Parcel ID: 210/104.A-0090-0000.0 SKETCH Click on Sketch to Enlarge 9 Page 1 of 1 Community: North Andover PHOTO No Ricture Available Location: 742 WINTER STREET Owner Name: CAGGIANO, MARK J T C/O MALLIN, AUDRIE & PAUL Owner Address: 742 WINTER STREET City: NORTH ANDOVER State: MA ZIP: 01845 Neighborhood: 6 - 6 Land Area: 1 acres Use Code: 101 - SNGL-FAM-RES Total Finished Area: 2280 sqft ASSESSMENTS CURRENT YEAR PREVIOUS YEAR Total Value: 534,400 500,300 Building Value: 324,400 306,000 Land Value: 210,000 194,300 Market Land Value: 210,000 Chapter Land Value: LATESTSALE Sale Price: 529,000 Sale Date: 06/24/2004 Arms Length Sale Code: Y -YES -VALID Grantor: COCHRAN, MICHELLE Cert Doc: Book: 8885 Page: 220 http://csc-ma.us/NandoverPubAcc/jsp/Ilome jsp?Page=3&Linkld=807749 9/8/2006 Commonwealth of Massachusetts City/Town of':5` System Pumping Record F,~ Form 4 r ° _ , 2013 Sv V T(j�Y<<, 0C 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 11sing'tt is'fiorm, 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, ' o , 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. �-t (,� a w t �e-,- 06f�"x City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code Statt e e, S"l, `j� Telephone Number \-13 Date 2. Quantity Pumped: Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Conditi n of System: � � 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: 1&5gina Lowe as Water auler Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date -3 t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts [REIVED City/Town of 5 'L`uiSystem Pumping Record -fH Form 4EPARTMENT ANDOVERV NORTH M yv 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: Lefllfront 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 {-7 L` � UU � _ 5�- oel ,{ ,\ City/Town 2. System Owner. Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code 5tate�} �� � 7QZi* de Telephone Number l Date 2. Quantity Pumped Cesspools) alSeptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ,[ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: , " 6. System Pumped By: Neil Bateson Name Bateson Enterarises Inc Company 7. Lohere contents were disposed: G.L.S. } Lowell Waste Water F5821 Vehicle License Number Date �7_ Ia t5form4.doc• 06103 System Pumping Recons •Page 1 of 1 1 4 n � a f WNL r aQrn C4 �" y o I X) p► d m� 3 � o ^ O � �m o: d D Z a s 4 � y a 1 4 n � a f WNL r aQrn C4 �" y o I X) p► d m� 3 A f, ►, r4 3 m /NV, f/8 m sar,is,/o- •�F • � 1J o c O �o y � O d b ' rn ny .. � l m b m b m cn 0 4 i11 0 ►, r4 3 m m • � 1J y � O d ny � ►, r4 3 m I~ {:� 3 -. w,. - it •. .y, - .L ` ) • •� � �„ °• , - { •-.r -�: Y- t¢ r ;al��.. 7' r` t��,�y� � , �. ..s �wr r ..�� a - , i •� � • t ^ 7 a• S w r .amt .. ` �• D .+:.. y r `r ...s '-.t J� G. �^� 11 • • , s 17 39 . /. .. 44 s: - I.�D»�.• ,.: Lam..'.,/: _. t �r� '` �� ��� y�^ •F�� IP Vi opal XA 1700 �0 T Gil a , ' \qr5 0D .~d- ��z-I(r�/ w t '9.. -.. - _ r o - y ... .. ♦ a .,. r a .w � +w Y . .4 `, • , � - l t r :. s! it . e ��. w '[ t t f i'•„ . „ l M - , .�� . r qt' ,J,.' � „ c, - rt, ' _. 7 • • sa- Da 4 :=•ir ••* ' s �' • w•,• ., � y . # r I' t$tiY-". _ ,. _ .. a.. ... _ .. s _ � ,•t � a • - _ . r '� ` tF..•� T. 41 1 '' 1 r 3,sl �# i 7:i. tr lr:. '.it • �s.h, r i s • k" sy ti •PUV g4JON 'Sa4PT30SSV I SeuTZaO 60 xuex3 NOVA UO Sau3a@NQ v gaZnnt %L d.zQlic Pue'suTW o.zQ„z 4ST • SUTW £ . awTs-„ g go o.zQ £ Z• awTs-„E in o xQ /,' M aWTJ,-4sa,y-..ze4S •suTW-NPOS uoT�e zn� eS 45p4S S T7 Z TZL Zo �� .zagwnN 4T(i /ire /% wa4eG-s4sas UOTgeToa.zaa ' wngeQ u014en9T3 UOTgPOOq OT OI 6 W L 9 S IVA E z I OI 0 8 L 9 0 c z I 6 8 A 0 0 0 0 ��•n9T3 t, 'n9T3 •� •n9T3 Z �A;DTS awa-9--ma5ua ribs 19n.zasg0 {7� JO4V6TgSaauj • o�'i�� .zauMo ueTd ��� c.,'( -Y2 • nTPanS/' ooj ON 407 _...�.,..i�_,}aa x S�' ou �TTO/uMOs rrr i..rr� Y VsVa ss3s NozsTIooa3a 's :aZz3o'da Zios r • It 0 CD 0 ca a 0 C p O 3� E � d � m v 3 J J O Z O o O a d w e a` � w �•+ lV0 w +r d w y O w LLA O d 3 y Q ai 3 a ayi w of CO N m m to o in a C1 co I- O O an = c m 0 co w d c � � v w y a'� �.. c o J z z zaNi O E d m � 3 d Z E O CLU y E y N z z z aCL y - Lo o a 3 H J k N W �o 'O p N � a C N v� a,o o E CD a m y o a a° C c a o E 3 3 .6w yM p a w o 0 LL 3 o e i- m o R o a `° c w C V c0 ow = C = d V O O cn C7 I°- cn C9 -j 0 CD 0 ca a W 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: _742 Winter Street _ North Andover_ Owner's Name: _Paul Malin Owner's Address: _742 Winter Street —North Andover, MA 01845_ Date of Inspections 8/30/2006 Name of Inspector: Neil J. Bateson Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810 Telephone Number: _( 978 ) 475-4786_ RECEIVE® SEP - 6 2006 TOHEALLTH DEPARTMENT OF NORTH ER CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority ils Inspector's Signature: Date: _8/30/2006_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: After permit from B.O.H., install new d -box, inspection from B.O.H., septic system now passes Title 5 Inspection. ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. f OWN w Q rt I 4�t 6 s Town of North Andover Animal $ ❑ 1S3ACNU�+t� HEALTH DEPARTMENT CHECK #: a4Mt1 LOCATION: 'pXi 04 /�- H/O NAME: llxyk /*1k;ll CONTRACTOR NAME: ���4911 Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title `5� Inspector $ �--�� M T� %itle 5 Report $ .��• ❑ Other: (Indicate) $ 1706 t, Iq,. - - Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer 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: _742 Winter Street —North Andover_ Owner's Name: _Paul Malin Owner's Address: _440 Winter Street —North Andover, MA 01845_ Date of Inspection: 8/10/2006_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, MA 01810 Telephone Number: _( 978 ) 475-4786_ RECEIVE® SEP - 6 2006 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 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 X Conditionally Passes Needs Further Evaluation by the Local Approving Authority Is e> Inspector's Signature: NT, , tDate: _8/10/2006_ The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments: ""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 l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: _742 Winter Street _ North Andover_ Owner•_ Malin_ Date of Inspection: _8/10/2006 _ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: X 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. D -Box needs replaced, badly corroded. N 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: N 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: N 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: _742 Winter Street _ North Andover_ Owner: _Malin_ Date of Inspection: _8/10/2006 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: T 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: _742 Winter Street _ _ North Andover_ Owner: _Malin_ Date of Inspection: _8/10/2006 _ D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: _ 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 1/2 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 I 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 'IW' 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: _742 Winter Street _ _ North Andover _ Owner: _Mahn_ Date of Inspection: _8/10/2006_ Check if the following have been 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 ? N/A _ Were as built plans of the system obtained and examined? _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. _Yes_ _ 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)] Page 6 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: _742 Winter Street _ North Andover– Owner: King_ Date of Inspection: _8/10/2006_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4 M DESIGN flow based on 310 CR 15.203 _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 reading: Yes _ Sump pump (yes or no): Yes_ Last date of occupancy: _Current COMMERCIALANDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): _gpd Basis of design flow (seats/persons/sgft,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 two years ago, owner _ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1000 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:–Design plan date is 11/27/1976, no 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: _742 Winter Street _ North Andover _ Owner: _Malin_ Date of Inspection: _8/10/2006_ BUILDING SEWER _ X _ (locate on site plan) Depth below grade: 26" Materials of construction: _X_ 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" cast iron thru wall, 3" PVC in house, no leaks. SEPTIC TANKS: X Depth below grade: _16" _ 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: 7' x 5' x 4' Sludge depth —6" _ Distance from top of sludge to bottom of outlet tee or baffle: 21" _ Scum thickness: _611 _ 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: 15" How were dimensions determined: _Tape Measure _ 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 baffle ok Outlet tee ok. Depth of liquid at outlet invert. No evidence of septic tank leaking in or out. _ 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.): Pages of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _742 Winter Street _ North Andover— Owner: _Malin_ Date of Inspection: _8/10/2006 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: gaflons 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 BOXS: Depth below grade _ 2411 _ 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 not equal. Evidence of leakage. Evidence of carryover. D -Boz badly corroded needs replaced._ PUMP CHAMBER: _ (locate on site plan) Pump in working order (yes or no): _ Alarm in working order (yes or no): _ Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Pap,9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _742 Winter Street _ _ North Andover— Owner: Malin_ Date of Inspection: _8/10/2006_ SOIL ABSORPTION SYSTEM (SAS): _X_ (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: leaching chambers, number: leaching galleries, number: _X leaching trenches, number, length: 2 trenches 40' long, 1 trench 251 _ leaching field, 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 oL Vegetation oL No sign of ponding to surface._ CESSPOOLS: Number and configuration: _ Depth — top of liquid to inlet invert: _ Depth of sludge 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: _742 Winter Street _ _ North Andover_ Owner: _Malin_ Date of Inspection: _8/10/2006_ 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 Septic Ti Ato1=18' Ato2=18' A to D -Box Bto1=9'2 Bto2=12' B to D -Box Page 41 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _742 Winter Street _ _ North Andover– Owner: _Malin_ Date of Inspection: _8/10/206_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to groundwater _ 4' _ 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: _11/27/1976_ 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: _ Design plan, no water 4' _ Summary Record Card generated on 8/11/2006 2:44:24 PM by Elaine Barclay • Town of North Andover ' Tax Map # 210-104.A-0090-0000.0 - 742 WINTER STREET ' PAUL MALIN AUDRIE MALIN 742 WINTER STREET NORTH ANDOVER, MA 01845 Page 1 _ Class 101 Single Family Property Type 1 Residential Size Total 1 Acres FY 2006 US Mailing Index Name/Address Type Loan Number Active/Inact. From Until PAUL MALIN Owner AUDRIE MALIN 742 WINTER STREET NORTH ANDOVER, MA 01845 CAGGIANO, MARK Previous Customer Inactive 6/25/2004 742 WINTER STREET NORTH ANDOVER, MA 01845 US Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 18146.0 - 742 WINTER STREET Last Billing Date 7/5/2006 3180174 03 Cycle 03 Active US Services Maint. Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 67.80 /1 US Meter Maintenance Serial No Status Location Brand Type Size YTD Cons 32945350 a Active ERT HH b Badger w Water 0.63 0.63 Date Reading Code Consumption Posted Date Variance 6/21/2006 20 a Actual 20 7/10/2006 -100% 3/18/2006 0 n New Meter 0 4/17/2006 -100% 3/18/2006 3427 r Replacement 15 4/17/2006 0% 1/3/2006 3412 a Actual 20 1/17/2006 3% 9/26/2005 3392 a Actual 19 10/14/2005 -4% 6/21/2005 3373 a Actual 21 7/15/2005 -4% 3/10/2005 3352 a Actual 14 4/5/2005 -11% 1/3/2005 3338 a Actual 23 1/14/2005 -15% 9/28/2004 3315 a Actual 27 10/8/2004 6% 6/23/2004 3288 f Final Bill 16 6/23/2004 103% 4/23/2004 3272 m Manual estimate 15 5/17/2004 0% 12/29/2003 3257 n New Meter 0 12/29/2003 0% Tel: (978) 475-4786 ' Fax: (978) 475-5451 BATESON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 742 Winter Street, North Andover Owner: Malin Date of Inspection: 8/10/2006 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. Nei?J)alesoiq Bateson Enterprises, Inc. Commonwealth of Massachusetts -CENED City/Town of System Pumping Record AUG 006 Form 4 TOWN OF NOR `H ANQO HEALTH UE''ARTIJENT DEP has provided this form for use by local Boards of Health.. The -System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When fining out 1. System Location- r _ forms the computer, use only the y b key Address �--�q to move our A), , cursor - do not Cit /Town use the�return y State Zip Code key. 2.. System Owner: 'Name Address (if different from•location) cityfrown State Zip Code 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): 4. Effluent Tee Filter present? ❑ Yes DIKO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � l of uler http://www.i t5form4.doc• 06/03 3ls/t5torms. htm#inspect Date System Pumping Record • Page 1 of t Or ° 111N� 7 T C".C"WICM �q rao 'Pa�4y PUBLIC HEALTH DEPARTMENT fommunity Development Division CER2'IFICA7E OF' COWPLT�1/CE As of.- September f September 12, 2006 This is to cert that the ind viduafsu6surface disposa[system received a. 1Distribution 00-1�, W -epfacement Compfeted by: Todd Oateson At: 742 WinterStreet XorthAndover, 914,4 01845 The Issuance of this cert f cate shaft not be construed as a guarantee that the system widl function satisfactorify. S an `Y. Sawyer, REjfs/R9 Pudfic 9feafth Director 1600 Osgood Street, North Andover, Massachusetts 01845 Phone 978.688.9540 fax 978.688.8476 Web www.townofnorthandover.com C f NCRYN Commonwealth of Massachusetts Map -Block -Lot °.•"'`° '°•,�oa 104.A- 0090 - n Board of Health Permit No • North Andover BHP -2006-0246 - . r i ..«� ... • ` P.I. � �°•-:°.''.�� FEE 133 cm SE< F.I. $125.00 ----------------------- Disposal Works Construction Permit Permission is hereby granted Todd Bateson to (Repair -D -BOX ONLY) an Individual Sewage Disposal System. at No --7-4-2--WINTER-STREET as shown on the application for Disposal Works Construction Permit No. BHP -2006-024 Dated August 14, 2006 ----------------------------------------------------------------- Issued On: Aug -14-2006 Board of Health ------------------------------------------------- M " 'o Commonwealth of Massachusetts Map -Block -Lot 0 104.A- 0090 - Board of Health -------------------- • North Andover ....p.�' is3t�' Certificate of Compliance ^ftNUs THIS IS TO CERTIFY, That the Individual Sewage Disposal System (Repair -D -BOX ONLY) by Todd Bateson Installer at No 742 WINTER STREET ---------------------------------------------------------------------------------------------------------------------------------------------------------- has been installed in accordance with the provisions of TITLE 5 of the State Environmental Code as described in the application for Disposal Works Construction Permit No. BHP -2006-024 Dated August -14,-2 - 006 ----------------------------------------------------------------- Printed On: Aug -14-2006 Board of Health a J 1 NOitTN q 0 • a Town of North Andover �+�'•l;`i HEALTH DEPARTMENT CHUSt� 1 CHECK #: LOCATION: H/O NAME CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Sustems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ B- Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ ❑ Title 5 Report $ ❑ Other. (Indicate) $ 1752 1 Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer t 0" 01945 TODAY'S DATE&'g.�� $ 250.00 — Full Repair .00 - Compon Important: Application is hereby made for a permit to: When filling out ❑ Construct a new on-site sewage disposal system* forms on the computer, use ❑ Repair or replace an existing on-site sewage disposal system* only the tab key to move your epair or replace an existing system component cursor - do notes use the return A. FaClllty Information — key. '� �� -SGA rah Address or Lot # � TJ NN OFTfit,";:DC's HEALTH DEPARTMENT rwn City/Town 2.- *TYPE OF SEPTIC SYSTEM*: ❑ Pump ravity (choose one) ***If pump. system, attach copy of electrical permit to application*** ❑ Conventional System (pipe and stone system) ❑ Infiltrator or Biodiffuser (Gravel -Less) (Attach a copy of your certification to install this type of system. ❑ Pressure Distribution S.A.S. (No D -Box) (Attach Draft Maintenance Agreement) ❑ Pressure Dosed (D -Box Present) S.A.S. 2. Ow Information 3. Name —I W s / Address (if differen fro above),,— ---- % City/Town Name - � �\ _c �` �t , Address Y�•/ City/Town 4. Desiqner Informati H 14- 01 ES Yom'-- StateZip Code Telephone Number Name of Company StaZiCode �� p Telephone Number (Cell Phone # if possible please) Name Name of Company Address City/Town State Zip Code Telephone Number (Best # to Reach) Application for Disposal System Construction Permit • Page 1 of 2 Z Jo Z aged - liwaad uoilonilsuoo walsAS lesodsia jo; uoileoilddy ON SdA —oN — saA —off D�7 —off y ''mss : (Aluo uoljan iisuoo Mau) z suvld .zoold 'S (uvrld pazocddv sv alms aucvs) :(Aluor uo 3na;suoo Mau) pyng-sy uozlvpunol -t, —SdA ;zuuadlvau;aalyo oo gaviiV,os jj zuza;s s ucndj -£ S 9 zpagov;;y uuol uoz;v�zlg0.cagvuvyy;aalocd -z zpagav;xb' aad 'l yup ash eoulo ao:i :suoseaJ 6UIM01101 ayj J01 panoiddesip uogeogddy ales oor aweN (ani;e;uasaadaa y;leaH Jo pMo8) -..A panddd uoileoilddy aleQ-91teN •y;leaH 10 paeo8 iQ' uaeq seyaoueildwoojoa;eoij!paoalr;unuoi;ejadouiwa;s�fsay;eoeldo;;ou yPoN jo uMol ay; ao{ suoi;eln6aa lesodsio aaepnsgnS le3o-7 ay; se Bann se 'apo le;uawuoJinu3 ay; {o g al;!l jo suoisinozd ay; y;!M aouepaooae ui wa;sAs /esodsip a6eMas a;is-uo paq►josep-ajoje ay; {o eaueua;view pue uoi;ona;suoo ay; ensue o; seeiBe peu6isaapun eyl luauodwoo - 00'9Zb$ iiedaa Ilnd - 00'09Z $ 31V(l SAVGO1 juaweeii3d •8 leiojawwoOE] ao 6uillam(] jei;uapisa ulplln8 to a j 'S ....penuiluoo uoilemiolul 4!1!3BA •d ZJOZ3OVd M10 VW ")IIAO(INV HDION 40 NI&O,I, - I!wJGd uoilmilsuoo ll w81s S !sso s!a 3ilcieS aol uo!le31I ti 2 INSTALLER PROJECT MANAGEMENT OBLIGATIONS As the North Andover licensed installer for the construction of the septic system for the property at 1L� -.C), lN\ relative to the application o�� !� dated 41�%� for plans by and dated with revisions dated I understand the following obligations for management of this project: As the installer I am obligated toobtain apattBoardnd tProved tn to performing any work on a stmusthehe approved pans and he permio prior when any work is being done. As the installer I must call for any and all inspections. If homeowner, contractor, project manger, or any other person not associated with my company schedules an inspection and the system is not ready then item three shall be applicable. As the installer I am required to have the necgssary work completed prior to the applicable inspections as indicated below. I understand that requesting an inspection, without completion of the items in accordance with Tile 5 and the Board of Health Regulations may result in a•$50.00 fine being levied against my company. a) Bottom of Bed - generally first inspection unless there is a retaining wall which should be done first. Installer must request the inspection but does not have to be present. b) Final inspection — Engineer must first do 'their inspection for elevations, ties, etc. As built or verbal OK from engineer must be submitted to Board of Health, after which installer calls for inspection time. Installer must be present for this inspection. With pump system all electrical work must be ready and able to cause pump to work and alarm to function. c) Final Grade — Installer must request inspection. when all grading is complete. Does not have to be on site. 4. As the installer I understand that only I.may perform the work (other than simple excavation) required to complete the installation of the system identified in the attached application for installation. I further understand that work by others unlicensed to install septic systems in North Andover can constitute reasons for denial of the system, and/or revocation or suspension of my license to operate in the Town of North Andover; significant fines to all persons involved are also possible. 5. As the Installer I understand that I must be on site during the performance of the following construction, steps: a) Determination that the proper elevation of the excavation has been reached. b) Inspection of the sand and stone to be used. c) Final inspection by Board of Health staff or consultant. d) Installation of tank, D -box, pipes, stone, vent, pump chamber, retaining wall and other components. 6. As the installer I understand that I am solely responsible for the installation of the system as per the approved plans. No instructions by the homeowner, general contractor, or any other persons shall absolve me of this obligation. Undersi icensed Septic Installer Date: l Disposal Works Construction Permit # r I � ! I I00 v I tir I •� I �¢w°zw II Iv'' Io I � L I I i I it � I i I U � o o I O I �i C> 1V (=>; N G i w 10' I vi V] rnlU Oi OII p ¢ iN p I U i z Q . 3 cd czIc CD a O O i �LQ d = s � y 0 0 Y TOWN OF NORTH ANDOVER Of NORTN 1 Office of COMMUNITY DEVELOPMENT AND SERVICES 3 `''�20°0 � a a HEALTH DEPARTMENT p ss i 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 •�, o�;*;D'�,�,�* NORTH ANDOVER, MASSACHUSETTS 01845 ,sS�cNus�< Susan Y. Sawyer, REHSIRS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX ONSITE WASTEWATER SYSTEM CONSTRUCTION NOTES LOCATION INFORMATION ADDRESS:-` q ® jl� MAP: LOT: INSTALLER: DESIGNER: PLAN DATE: BOH APPROVAL DATE ON PLAN: INSPECTIONS TANK INSPECTION: DATE OF BED BOTTOM INSPECTION: DATE OF FINAL CONSTRUCTION INSPECTION: DATE OF FINAL GRADE INSPE TION: 1 SITE CONDITIONS [-]Existing septic tank properly abandoned [-]Internal plumbing all to one building sewer []Topography not appreciably altered Comments: SEPTIC TANK ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ 1500 gallon tank has been installed H-10 loading Monolithic construction ❑ Water tightness of tank has been achieved (Visual or Vacuum Test or Water held for 24hrs) ❑ Inlet tee installed, centered under access port ❑ Outlet tee (gas baffle or effluent filter) installed, centered under access port ❑ 24" inch cover to within 6" of final grade installed over one access port, must be over outlet of tank if effluent filter is present ❑ Hydraulic cement around inlet & outlet Wastewater System Documentation — Feb 2006 Page 1 of 6 TOWN OF NORTH ANDOVERpE NORTh 1 Office of COMMUNITY DEVELOPMENT AND SERVICES a ,_�.° , ti°L ? e�.,e p HEALTH DEPARTMENT A 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 ♦ o*. r i NORTH ANDOVER, MASSACHUSETTS 01845 Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX Comments: PUMP CHAMBER ❑ Bottom of tank hole has 6" stone base ❑ Weep hole plugged ❑ Combo Tank installed. Size: ❑ 1000 gallon Pump Chamber installed H-10 loading Monolithic construction) ❑ Inlet tee installed, centered under access port ❑ Pump(s) installed on stable base ❑ Alarm float working ❑ Pump On/Off floats working ❑ Separate on/off floats ❑ Drain hole in pressure line ❑ 24" inch cover to within 6" of final grade installed over pump access port ❑ Watertightness of tank has been achieved Visual testing ❑ Hydraulic cement around inlet & outlet Comments: ADVANCED TREATMENT TECHNOLOGY ❑ Type of treatment device: Comments: ❑ Installed per manufacturers requirements ❑ All components working in accordance with manufacturer's requirements Wastewater System Documentation — Feb 2006 Page 2 of 6 r TOWN OF NORTH ANDOVER f NORTH 16 Office of COMMUNITY DEVELOPMENT AND SERVICES �e HEALTH DEPARTMENT ~ 1 ~ M4 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 NORTH ANDOVER, MASSACHUSETTS 01845"SS cH„5e<� Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX D -BOX [� Installed on stable stone base Inlet tee (if pumped or >0.08'/foot) Hydraulic cement around inlet & outlets Observed even distribution Speed levelers provided (not required) Comments: SOIL ABSORPTION SYSTEM Comments: r1 u El Bottom of SAS excavated down to soil layer, as provided on plan Size of SAS excavated as per plan Title 5 sand installed, if specified on plan 3/4-1 '/2" double washed stone installed 1/8-1/2" (peastone) double washed stone installed Laterals installed and ends connected to header Laterals vented if impervious material above Orifices @ 5 & 7 o'clock positions Gravel -less disposal systems: type, number and location as per plan Elevations of laterals installed as on approved plan 40 Mil HDPE barrier installed Retaining wall (boulder / concrete / timber/ block) Final cover as per plan Wastewater System Documentation — Feb 2006 Page 3 of 6 TOWN OF NORTH ANDOVER of NORTH, Office of COMMUNITY DEVELOPMENT AND SERVICES o *,7 HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 ",. ,� •" NORTH ANDOVER, MASSACHUSETTS 01845 ��Ss'C U Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX PRESSURE DISTRIBUTION 1-1 El Comments: CONTROL PANEL Comments: -- inch manifold laterals installed with end sweeps size: material: Squirt test ft in height Equal distribution to all laterals orifice size inch as per plan ❑ Alarm & Pump are on separate circuits ❑ Alarm sounds when float is tripped ❑ Location of control panel: ❑ Rated for exterior if placed outside Wastewater System Documentation — Feb 2006 Page 4 of 6 r ' TOWN OF NORTH ANDOVER Ct gORTH Office of COMMUNITY DEVELOPMENT AND SERVICES HEALTH DEPARTMENT J p 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 "e NORTH ANDOVER, MASSACHUSETTS 0184"Ss" CH„ est Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX CRITICAL SETBACK DISTANCES Mark those distances checked in the field against the design plan and regulatory setback ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 Tank SAS Sewer ❑ Property line 10 10 -- ❑ Cellar wall 10 20 -- ❑ Inground pool 10 20 -- ❑ Slab foundation 10 10 -- ❑ Deck, on footings, etc 5 10 -- ❑ Waterline 10 10 10' ❑ Private drinking well 75 1002 50 ❑ Irrigation well 75 100 ❑ Surface Water 25 50 ❑ Bordering Vegetated Wetland , Salt Marsh, Inland / Coastal Banka 75 100 ❑ Wetlands bordering surface water supply or trib. (in Watershed) 150 150 ❑ Trib. to surface water supply 325 325 ❑ Public well 400 400 ❑ Interim Wellhead Prot. Area ❑ Reservoirs 400 400 ❑ Drains (wat. supply/trib.) 50 100 ❑ Drains (intercept g.w.) 25 50 ❑ Drains (Other) Foundation 10 (5) 20 (10) ❑ Drywells 20 25 ' Suction line 222(2) 2 100 feet is a minimum acceptable distance and no variance is allowed for a lesser distance (NA 5.02). 3 As defined in 310 CMR 10.55, 10.32, 10.54, and 10.30, respectively, pursuant to 15.211(3), also by NA wetland bylaws Wastewater System Documentation — Feb 2006 Page 5 of 6 TOWN OF NORTH ANDOVER pE NpeTH Office of COMMUNITY DEVELOPMENT AND SERVICES a `4 �C ? e .a • '. e p HEALTH DEPARTMENT 1600 OSGOOD STREET; BUILDING 20; SUITE 2-36 *• ",..r +" NORTH ANDOVER, MASSACHUSETTS 01845 �'"'ic USt�' Susan Y. Sawyer, REHS/RS 978.688.9540 — Phone Public Health Director 978.688.8476 — FAX SYSTEM ELEVATIONS Building Sewer OUT Septic Tank IN Septic Tank OUT Pump Chamber IN Pump Chamber OUT Distribution Box IN Distribution Box OUT Lateral 1 HIGH Lateral 1 LOW Lateral 2 HIGH Lateral 2 LOW Lateral 3 HIGH Lateral 3 LOW Lateral 4 HIGH Lateral 4 LOW Lateral 5 HIGH Lateral 5 LOW INVERT ON DESIGN PLAN FIELD INVERT ELEV. Wastewater System Documentation — Feb 2006 Page 6 of 6 Alvwver as 4.* Ind Moen STEWTOS SEPTIC TANK SERVICE A 47 RAILROAD STREET BRADFORD, MR 01835 Wdoul Lit - 978 -372-7471 itlC4C4ll Lj e- Kwm OF Lbae —r o, MMnW REPORT MR TOM OF DATE ADDRESS i CSX t GAIZDNS1p�� 1556 i&l--1 1506 1400 106L 1 bcv loed kw 05�cj 160) lab 0 av) 4�z'7' 'o 763 Ul ------------ -Na Cil 44r,5� n" Or -Ld �-dl � Ll /-J, —Flq Ism r s rq� 13 1r f----------- 15 -'�v cxc'�- I'll ? 1556 i&l--1 1506 1400 106L 1 bcv loed kw 05�cj 160) lab 0 av) ARGEO PAUL CELLUCCI Governor COMMONATALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 0210£ (617) 292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM /,' / PART A 71/,2 if / llre lz ,S"? CERTIFICATION Property Address: P. Am'q Q U erz, Name of Owner ro C 14 /�71V Address of Owner: Date of Inspection: SC104 ,Q Name of Inspector: (Pie ase Print) 1 S'4 1 am a DEP app oved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: /- P /L j>c "%/ G Mailing Address: L/'7 /L/1 /U,e a. n Sr— Telephone r—Telephone Numbw: '?,F' 37 2 • 7 V7 � TRUDY C0XE Secretanv DAVID B. STRUHS Commissioner 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 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 Fails Inspector's Signature: L6t'e'� Date: The System Inspector shall submit a copy of this inspection 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 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. NOTES AND COMMENTS revised 9/2/98 rage 1 of ll `i Pnrtrd or Rery<Ird Papr, U r SUBS URFACE'SEWAG E DISPOSAL SYSTEM INSPECTION FORM PART A ,� /%� 1J ERTIFIC�Q��I„Ic�rt6t lnued� ,V ,J/D 'roperty Address: (�'r' �r Jwrter: C Date of Inspection: 2- 7 r D 0 INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: #i 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: f'I. /�'t- 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 Boaid 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. 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. 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 levelled 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): broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2ofII r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 12 TV / /V C� S f : il Owner: � Date of Inspection: /0-2-7-00 7-p0 C. � FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: IU.Pf 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: Cesspool or privy is within 50 feet of surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh. r 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH IAND PUBLIC WATER SUPPLIER, IF ANY) 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 (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 soil absorption system and the SAS is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER revised 9/2/98 Page 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A • CERTIFICATION (continued) Property Address: * G 'All /1/ ! e ``- s / • Owner: b C. Date of Inspection. M - 27- © 0 D. SYSTEM FAILS: �Y ust indicate either "Yes" or "No" to each of the following: , 1 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 contacted to determine what will be necessary to correct the failure. Yes No Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool. Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool. Liquid depth in cesspool is less than 6" below invert or available volume is less than 112 day flow. 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 elevation. Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well. Any portion of a cesspool or privy is within 50 feet of a private water supply well. Any portion of a cesspool or privy is less than 100 feet but greater then 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: 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: �r y The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public rL health and safety and the environment because one or more of the following conditions exist: 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) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the Department for further information. revised 9/2/98 Page 4ofII 9 ,A SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST %� Property Address: 74 21VY VVIAI V �� %I Ql ' if r `1 a ✓ e Owner: C Q G 7( /C fi %✓ i Date of Inspection: /0 ?— 7- Q Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yew,.._ No Pumping information was provided by the owner, occupant, or Board of Health. _ 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 f ,} inspection. As built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout. All system components, excluding the Soil Absorption System, have been located on the site. 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: _ Existing information. For example, Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)] The facility owner (and occupants, if different from owner) were provided with information on the proper maintanawA of SubSurface Disposal .Systems. revised 9/2/98 page 5of11 ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM s PART C /[ SYSTEM erty � - /Y INFORMATION/� OropAddress: T / %� f I� /► ' /D/ 0 V (f ' 1. M r l Owner: 4 C N/ Date of Inspection: /0-27-00 O27-0 FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroo Number of bedrooms (design): Number of bedrooms (actual):— Total DESIGN flow Number of current residents: Garbage grinder lyes or no):p Laundry (separate system) (yes or no):h/v If yes, separate inspection required Laundry system inspected (y9s or no) Seasonal use (yes or no): Hd Water meter readings, ifavail ble (last two year's usage (gpd): Sump Pump (yes or no):H Lest date of occupancy: it up I 'e t n COMMERCIAL/INDUSTRIAL : tA Type of establishment: Design flow: qpd 1 Based on 15.203) Basis of design flow 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: OTHER: (Describe) _ Last date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: H.A . System pumped as part of inspection: (yes or no):Y iv If yes, volume pumped: gallons f Reason for pumping: TYPE% ,SYSTEM I.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) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval ( ' Other APPROXIMATE AGE of all components, date installed (if known) and source of information: % 1' vV 5 Sewage odors detected when arriving at the site: (yes or no) SO revised 9/2/98 Page 6of II w SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: 7' 11z fV t !V A e � owner: C 0 C Date of Inspection: /o -2-7- r I / Q/T O 7 -- BUILDING SEWER: (Locate on site plan) Depth below grade:3-4 Material of construction: _►'cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line /0 0 /r Diameter L ► ( Comments: (condition of joints, venting, evidence of leakage, -etc.) u SEPTIC TANK:, N (locate on site plan) •Ir r. Depth below grade. Material of construction: _ oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is metal, list age _ Is.agee confirmed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle:-,A- Scum affle:Scum thickness:` (/ Distance from top of scum to top of outlet tee or baffle: I/ Distance from bottom of scum to bottom of outlet tee or baffle:% How dimensions were determined: L7 /,/ ,r1 r e- 'omments: (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.) GREASE TRAP: locate on site plan) NW Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: ¢ Distance frotop of`'scum to top of outlet tee or'baffle: t Distance from bottom of scum to bottom of outlet tee or baffle: Date of lest pumping: 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.) revised 9/2/98 Page 7or11 r SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM + t PART C SYSTEM INFORMATION (continued) 'roperty Address: e S f �✓ �¢ n�% 0 ✓ e Owner: O C # /? Date of Inspection: � 1 A IV TIGHT OR HOLDING TANK. (Tank must be pumped prior to, or 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 Alarm level: Alarm in working order: Yes _ No f k t Date of previous pumping: r Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX:y( s (locate on site plan) Depth of liquid level above outlet invert: / Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER:_ A/ (locate on site plan) 4. Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of' chamber,`condition of primps and appurtenances, etc.)' i j+a v 4'o , e� p t revised 9/2/98 Pa Fe 8ur Il i• a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM fi. + PART C SYSTEM INFORMATION (continued) 4operty Address: L j z W tO� lP J �-' „• �j N '92 f /V Date of Inspection: � _ ©� f/I SOIL ABSORPTION SYSTEM SAS1: (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:_ leeching chambers, number:_ leaching galleries, number:_ �. leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: i Name of TecHnology: r r. ` Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) /� 1.. i /� a w' T /f Ll , i % uA I CESSPOOLS: _ (locate on site plan) Number and configuration: //Tn Depth top of liquid to inlet invert: Depth of solids layer: )epth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater: inflow (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) PRIVY: _ 0% 1 ) *1 r (locate on site.plan) �` v +� '�„ •! a . e Materials of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) revised 9/2/98 Page 9of11 * SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM A PART C SYSTEM INFORMATION (continued) Nop" Address: 4W D o vle 14 )weer: Ci d e 2—, ` ', " Date of Inspection: r ! SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (locate where public wat�r supply comes into house) revised 9/2/98 Page 10ofII revised 9/2/98 Page IIofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C �. SYSTEM INFORMATION (continued) operty Address: 2. 4/( A(4 �/-Y t + / q d j ,O Vif / Jwner: 0 e / Date oflnspection: /r ' L ,c 1>M%AAA NRCS Report name ~'- --- Soil Type_ 11�pical depth to groundwater \ \ \ \ VA u ! I USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope Surface water Check Ce)lar 1 Shallow v6lls Estimated Depth to Groundwater _ Feet Please indicate all the methods used to determine High Groundwater Elevation: rr Obtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) L//Determined from local conditions Checked with local Board of health Checked FEMA Maps Checked pumping records Checked local excavators, installers Used USGS Data Describe how you established the High Groundwater Elevation. (Must be completed) 1/0 I• 1 t t� � t' f., � � � � C, f� 6� G'P revised 9/2/98 Page IIofII Commonwealth,of MomIchusetts Executive Office of EnvironMenf l Affairs eppt ntf Environmental Ptec ion r°wN of No Wlaiam F. Wold BF? OARD ANb Trudy Coxa H 3ocretwry, BOF r�A David 6StiWAS tial 7 l commi"110m i SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION OR PART A MTIFICATIO�N, Property Address: ` �%�% Gl��`r1 �/�!� 6 el¢ �roc+wV/� Address o.f_.OWners Date. of Inspection; .���5��5G (if different) Name of Inspector; h . of �Ql�p f Company Name, Address and Telephone Number NF.W ENGLAND ENGINEERING SERVICES; . INC. 33 WALKER ROAD P.O. BOX 536 - .CERTIFICATION STATEMENT NORTH ANDOVER, MA 01845 508-686^176$ . I ce(I that I have perscnaliy..insAeaed the sewageldisposal system at this, address and that the Information reported below. Is true, accurate and complete, as of the time o(lnspection. The inspection. was performed based on my, training and experlence in the proper function aril maintenance of on-site'. n-site sewage. disposal systems. The system:' +rPasses .._ . Conditionally Passes` Needs Further Evaluation By the Local Approving Authority Fails In PecIor's Signature: Date: The sy5lem Inspector shall6ubmit apy of this inspection repon to the Approving Authority, within thirty (30) days of completing this nsper.on. if the $ystem is a shared system or. has a:design,flots�.of.t0,000 gpf or greater, the,inspector and.the system .owner shall submit the. report to. the appropriate regional office 'of the Oepanment.of Environmental Protection; The original should pe sent ti;. tnF s%stem owner ano coptt:s stilt to thr.bu)i,r,'.if applicable and the approving.au!hnrl;t, INPEC"ION SUMMARY; Check_A, 51 C. or G. A) SYSTEM .PASSES: /have, not'fo:und any information which indicates that the system violates any of.the failure criteria as defined in 10 CMR 15.303. Any failure criteria not evaluatec are indicated below. 8j :SYSTEM CONDITIONALLY PASSES: One or mere 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 not) The septic tank is metal, 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_'conforming septic tank as approved by the Board of Health. ,.ei.sed 8;:5!55' t Oa a Wlnt�r; Street o � ptori, Kaa}zc t.uautt» Q?146. o FAX (617) 5.5&-1049 o Tolophon.* (617) 292.5600 SUBSURFACE :SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) . Property Address; e"j SYSTEM: CONDITIONALLY PASSES (continued) ' ..Sewage backup or breakout or high static water level observed in the'disttlbutlon box is due to broken or obstructed ipe(s} or due to a broken;'seRied yr uneven dlstributlon .box. The system .will pass inspection if (with approval of the p, Board of,Hea.ith)' broken pipets) are replaced bst rust{ on removed em oved Obstruction disureplaced {but{on box.{s leveller or, r than four times a year due, to broken or.obstrucied:ppe(s); The system. will pass d rnin.moet . {r v The system required p P g, � , 1 �" f h e Board of Hea th); In' ection if ,(with app o val:o t .P are replaced broken i e(s) p P P obstrvction is removed Cl FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH; i. Conditions exist which require further evaluation by the' Board;of Health in order to determine if the 'system IS falling io protea the public `health„ safety and the environment.! 1) SYSTEtst :WILI "PASS UNLESS BOARD OF' -HEALTH DETERMINES. THAT THE SYSTEM IS NOT FUNGTLONING IN A MANNER WHICH ,.WILt PROTECT THE<P,UBLIC ,HEALTH AND SAFETY,AND THE ENYLRONMENT{ Cesspool or prn.y is within SO feet of a surface ,N..ater . ',Cesspool or Privy. is within so feet of a bordering vegetated .wetland or aaalt marsh" 2? SYSTEM, FAIL QNLESS'THE BOARD F HEALTH.(AND PUBLIC WATER SUPRLIER, IF ,SAFET ANDIATE) DETERMINES THr�7 THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE E,NVIRON.NAEN T, . i.` ThP S%StPm h8i d se.D11c'tanK ano sort absorption 0lem and ,$ within 100 feet Wa nu4f watc{ swpp +, 4i Uibutaf) tS d surface "•atel 5UPply. Thc.S�stvm har a seotie tank and ,soil absorption system and is within a done i of a public water supply well; The st'stem'h5s a sepllc.tank and soil. absorpticm,system and is within 50 feet of a private water supply well, The sy trn ha, a SNpI�� tank and:loll absorption system and is less than 100. feet but 50 feet or more from a private ;avater bacteria and volatile,�organ c. compounds indicates that the well is, rcoliform w r'' -snot sly for at I e supal� »ell, unless a we I Y free from pollution: (rorri, that. 361ty and the presence of ammonla nitrogen and nitrate,nitrogeri'Is equal to or less than 5 . ppm. pJ SYSTEM FAILS ' ates one or more 'of the following failure Criteria as defined in 310 CMR 15,303. The basis V{fl 1 he s st m t correct " t o or fined ha 3 Y @ necessary C e I have determined l what will be ry h for this determination is identified below. The Board of Health, should be contacttid to determine the failure. Backvp of sewage Into facility or system Component due to an overloaded or clogged SAS or cesspool.. Discharge" or ponding of eNluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool: 2 _ Irew:sed 0;:5.!951 5i� ',/n SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART 'A CERTIFICATION (continued) i'roperty Address;. 7��.0Are 1poe# Date ,of Inspection: D) SYSTEM FAILS (continued): Static liquid level in the dlstribution box above outlet -Invert due to an overloaded or..e o"o SAS or cesspool,_ Liquid.depth In cesspool is less'; than 6" below invert or available volume Is less than 1/2 day flow. Required pumping .more than il times in the last year )`10T due to clogged or obstructed; pipets).. . Number of times pumped _ Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation, Any portion of a cesspool or privy is within 100 feet.of a surface water supply Or tributary to a surface water supply. An, onion of a cesspool or riv, is within a Zoned of a public well, � n p P � Any portion of a cesspool or privy is:within 50 feet of a private water supply well. Any ponlon•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., it. 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,: F! LARGE SYSTEM FAILS: The'following criteria apply to large systems. in addition to the criteria above: The oesi&n. f!r •'of systenm is 10,000 gpdotgreaier (Large System) and the system Is a significant threat to public health and.safery and the: ei;ti rornient because one or mote of the (oil ,owing conditions exist; the system is within 400 feet of'a surfaceface drinking wafer sup ply the system is Within 200 feet of •a tributary to a surface drinking water supply the system is louied in.a nitrogen sensitive area (interim Wellhead Protection Area (IWPA) or a mapped Zone 11 of a puWlc v,dt2i supp!; 'well; The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program requi ernents of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further Information, 3 I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address, 7 i ty Owner; pt d,t'P Date of inspection; :Check, if the following e been .d. one: . hay i _Pumping Information was requested of the owner, occupant, and Board of Heal(h..' . None of the system components have been pumped (or 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; rLs G a;4 1 �s t3 V AA-J=14.plans: have been. obtained :and ex.amined, -note if they are not available with NIA. p The facilih° ordwelling was inspected for signs of sewage backup. !: The system does not receive normanitar), or industrial waste flow he. sit was inspected.for signs of breakout, All system components, excluding the Soil ,Absorption System, have been located on the site. e . The:septic tank manholes were, unoovered,-opened, and the interior of the septic tank was inspected (or condition of baffles or tees,: material of construction, dimensions; depth of liquid, depth of sludge,. depth of scum, ZThe size and lgcatlon of the Soil Absorption System on the site has been determined based on existing information or approximated by non•intru9ive methods.; . The.fdCn,l C'.. rC' (un .00C {1.'^;`, if d ftC,^';. (;^^` O�% aBr! wr?re prv�'ided will inormatinn. on the proper maintenance. of Sub. Surface Disposal System, aa�isdd a;�5%.951 4 • �� - 6 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C // :SYSTEM/ INFORMATION .. ., property Address: �y. %�r` n� , Sl. IA ell A. 112,e, Cale ei inspection; FLOW CONDITIONS Design flow; _.._, ..gallons . Number of bedrooms;,4, Number of current residents GarbaEe grinder (yes or noI:_A-lo Jnr? " connected to system (yes or no):4-1 Seasoned use (yes or no), Water meter readings; if available: u last dnte of occupancy!; avn COMMFRCIAt✓'INDUSTRIAI; Type.of establishment: Design flow., ailon.srday ... . Grease trap: present; (yes or no) ;ndustri3l Waste Molding Tank present: (yes or no)___ Non sanitary -waste discharged to the Title 5 system. (ye.s or no)__ ater Pieter.readings, if. available; last da;e-of occupancy: OTHER: (Describe) Last date of oCeupaIICY: „ GENEKAL INFORMATION pUMPING :RECORDS and source of information:, o 1p. 1,17, System pumped as pan of inspection: (yes or no) If,yes, volume.R,m,lVd –.1--rd9110's Reason.for pumping: c TYPE OF SYSTEM' .. Septic, tankrdistnbution;boiJsoil absorption system .Single cesspool :. . "Overflow. cesspool.: Privy It n ' records, 1 any) n o hl Ng10 eC Shared system (yes or no) ,if yes, attach previous sp Y her(explalnJ Ot - APPROXIMATE AGE or all components', date installed (if known1 and source of information: Sewage odors detected when arriving at ihe. site: Lyes or no) !Vd trev.se.8/:5/951. 5 ...,�..�-..w..���._,__.__ _ ....- ,$ ....,._,_.::�...._._..____.._...w_�._._.�,. rrv.v•.d.6!15/95; y � •�_:r....7.. I..�•l�a:rl.1y. L. � I—� .. ,5.t�x. .w a� ��, ''.`r `. ��. ,t yl` .4•� �. ,^� q4JON / 2Vpub cSa�2T0OSS� g SeuTja0�}UL(/x3 1 Sa'U��J o 1a cap nor rGc/ c.rcc/ E`. (27 ojc,, c PUe ° SUTW OzQt,i �SZ'SUTW awTI-„ 9 ;o o za p awTs-t, £ ;o doic / 'suTH-NPOS uoigpjngeS gjagS S £ Z Z jagwnN 4Td 01 6 IH IFA 9 s 91 z a4aa-s4sas� oT4joo.zad wngPa UOT4 oOrj OI W w V z 6 C uoT4EnaZ3 Njpwuouag Z L J 9� t t t t e 0 0 0 • naT3;---, nL L z� // 0 alva-s3'II3oud 'Ilos oS J9AJasg0 O�/v .—`07 4 04E5z:4s9nul N 'ON 40'I �� �Y' `4aa,r4S'8'oN A4;O/UMOj V-LVa 1931 NOIIYIO:)H3d 12 3'II302Id 7I05 / ' DATE_ SYSTEM/'OWNER & ADDRESS TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD SYSTEM LOCATION ,- 6rn� AND f9 I-, u,.EAL pop OF._ f DATE OF PUMPING z(d-2;_.QUANTITY PUMPED_ZQ]�f j CESSPOOLNOI e�- — l - YES SEPTIC TANK NO YES NATURE OF SERVICE: Rd5UTlNE_z4 EMERGENCY OBSERVATIONS: GOOD CONDITION 07k FULL TO COYER HEAVY GREASE BAFFLES UNLACE ROOTS LEACEFIELD RUNBACK-�= EXCESSIVE SOLIJDDS 'FLOODED SOLID CARRYOVER OTHER EXPLAIN SYSTEM PUMPED BY COMMENTS; CONTENTS TRANSFERRED TO COMMONWEALTH OFMASSACHUSETTS J.— -'EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION TITLE 5 1 L OFFICIAL INSPECTION FORM - NOT FOR LOLUNT-ARVIESSE&S SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM Property Addre! Owner's Name: Owner's Addres Date of Inspecti( PART A CERTIFICATION Name of Inspector: (please print) SQ M J; u-sa- Company Name: SLIbA)j? r-hS Mailing Address: n?L) .0-3r174*>art9, M/7 . 0I835 Telephone Number: .(q ag5`7AI - 9 -QW 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 Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: 4440 Date: 2 -- The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments ****This report only describes conditions at the time of inspection and under the conditions of use at that time. This inspection does not address how the system will perform in the future under the same or different conditions of use. Title 5 Inspection Form 6/15/2000 page 1 $ Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A , CERTIFICATION (continued) Property Address: %y2 w1n4-er ST Q /) V P 11 . Owner: C:r (? r/7 Al Date of Inspection: H /5/o Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: , / �s 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 pipes) 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): ND explain: broken pipe(s) are replaced obstruction is removed 2 Page 3 of l l OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 9'VC , W l -a4er —'�; r NQ 0NW1,� , M G! _ Owner: ("'6( f'r/,7N _ Date of Inspection: .4115'14V C. Further Evaluation is Required by the Board of Health: /\/- 14 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 I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: '74,?- 1 i 1�4,v —;T Owner: ( J Date of Inspection: D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No ---Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ _--Dischafge or ponding of effluent to the*surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than 6" below invert or available volume is less than ''V2 day flow Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _ Any portion of the SAS, cesspool or privy is below high round water elevation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone 1 of a public well. _ Any portion of a cesspool or privy is within 50 feet of a private water supply well. "Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory, for 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.] %v (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: : I 't r 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 low - M OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: / -7a, Wll�iw S Jyh. okirVeK, n)� Owner: N Date of Inspection: D Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No , u� Pumping information was provided by the owner, occupant; or Board of Health Were any of the system components pumped out in the previous two weeks ? c / _ Has the system received normal flows in the previous two week period ? --"Have large volumes of water been introduced to the system recently or as part of this inspection ? _ 114 Were as built plans of the system obtained and examined? (If they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up ? _ Was the site inspected for signs of break out ? Were all system components, excluding the SAS, located on site ? _�_ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum ? — 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,hetermined based on: Yes no _ Existing information. For example, a plan at the Board of Health. Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 CMR 15.302(3)(b)] 5 Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: / `T� W/ S7 -. 4Z/0- 2AILOV10 k; - Owner• G - Date of Inspection: V ZEZn FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): Number of bedrooms (actual): L/ DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents. 4_1 Does residence have a garbage grinder (yes or no): /'/0 Is laundry on a separate sewage system (ye`s or no)',_ [if yes separate inspection required] Laundry system inspected (yes or no):JUo Seasonal use: (yes or no): r/o Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no): VC 5 Last date of occupancy: /_� r e- C'P P COMMERCIAIANDUSTRIAL 1-14 Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgR,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: 5 Was system pumped as part of the inspection (yes or no): ✓ If yes, volume pumped%gallons -- How was quantity pumped determined? S/L ,� Alit Reason for pumping: /" C r �? TYPE -OF SYSTEM Septic tank, distribution box, soil absmptirm 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: 1:12..5 V Were sewage odors detected when arriving at the site (yes or no): 'd_1 6 w. Page 7 of I 1 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: rl * s� W2. omn Ve Owner: 14 19' Date of Inspection: 1 ( i.oMI-an BUILDING SEWER (locate on site plan) Depth below grade: 3 z Materials of construction: cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage,.etc.):' SEPTIC TANK:.LS (locate on site plan) / Depth below grade:l[' 4 � Material of construction: _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: 5� Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: 3 Scum thickness:y `I , Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How were dimensions determined: Jou SL Tt 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-,4e CQ N /7j Z/d. 4 GREASE TRAP:/ocate on site plan),F 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 l l OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:_ -%ZI ,Tc' S r U CiIV �aDVPt_Ci Owner: Date of Inspection: D TIGHT or HOLDING TANK: CL (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.y (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert:,E2� d / 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.): PUMP CHAMBER: locate on site plan) Pumps in working order (yes or no): Alarms in working order (yes or no): r 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: r74-9 . i) Owner: _/; y Date of Inspection: , SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: fi Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: / d ti a 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:A/' " (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: ?. 1'l(r�Pi' Ivo • 12A)PI fe- Owner: _.0( 1 Date of Inspection: _ /�i //) q 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. 0 oX zl. 10 . Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 74 ) _ 11 )/1)4 mi Owner: � (�[� Y� /�/ Date of Inspection: SITE EXAM Slope Surface water Check cellar Shallow wells , S Estimated depth to ground waterer L- feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: Z/ 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: ,f5a7ro Qr n. c.,J,�� d Al (j 4Z%2 S r 1 TOWN OF JAI - SYSTEM PUMPIN DATE: ui- 0 4 SYSTEM OWNER & ADDRESS Art�' tV\— 5� 4), ysq-r DATE OF PUMPING: - (} CESSPOOL: NO J YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER �5 SYSTEM LOCATION (example: left front of house) r QUANTITY PUMPED: COVED OCT 19 2004 TOHEALLTHOF IDEPARTORTH M TER PTIC TANK: NO EMERGENCY YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIlS) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.Dy/ Lowell Waste GALLONS 7 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. nim Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1 System Location: Address Qj I'� �/�J I ,I / k \-/\City/Town 2. System Owner: Name Address (if different from location) Cdvrrown (f� vvdvSQ B. Pumping Record t 1. Date of Pumping 8-,a3-07 Date State V\, , Stat � � 7jP� e Telephone Number 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) e-ge-p-'tic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes a -No If yes, was it cleaned? ❑ Yes ❑ No 5. Conditiory� bl&� 6. System Yu",By: Name Company 7. Locationr contents a di o d: Vehicle License Number Date t5form4Ad c- 06/03 System Pumping Record - Page 1 of 1 Commonwealth of Massachusetts w r0 City/Town of RECEIVED System Pumping Record Form 4 AUG 2 4 2009 H ANDOVER DEP has provided this form for use by local Boards of Health. Ottu>��dYb the information must be substantially the same as that provided here Is orm, 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 side of house, Right side of house, Left front of hqCse, Right front o house Left rear of house, Right rear of house. Address City/Town State Zip Code 2. System Owner: Name _ Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): z5tate(r—,,,0 2 `O / Ze Telephone Number Date 2. Quantity Pumped Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V 6. System Pumped By: Neil Bateson �S<o /Wlz� Name Vehicle License Number F5821 Bateson Enterprises Inc Company 7. Location here contents were disposed: G.L. Lowell Waste Water Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key ®I ree�n Commonwealth of Massachusetts RECD City/Town of System Pumping Record AUG 18 2008 Form 4 TOWN OF NORTH ANDO`JER l FALTH D� PARTMtt�!T DEP has provided this form for use by local Boards of Health. Ot r,QA1rn Aay"---tused;'-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 I. System Location: Address 'J" t L�ll _ 4 , City/Town 2. System Owner: Name Address (if different from lavation) State r--Let3w� Zip Code CitylTown State/' (4:5_ &'-7 �q 1e� Telephone Number , 1 B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 2-'Lr3"M Date 2. Quantity Pumped Cesspools)eptic Tank 4. Effluent Tee Filter present? ❑ Yes 9-90 5. Condition of System: (-M Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No 6. Systrn umBy: Name Vehicle License Number Company 7. Location where contents we disposed: �' „� �. Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of -- System Pumping Record Form 4 X00 IQ 2010 DEP has provided this form for use by local Boards of Health. Othe E MMMT--'- information must be, substantially the same'as that provided here. with your local Board of Health tQ, determine the fomithey use. The System Pumping Record must be submitted to the local Board of Health ovoth r approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house I t front Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address l� t �l�f •.d'lti. City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town State/J_ &_ —L nde �o ' 7 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): 4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition oSystem: ►v�`v`- ��-� �,�-BC/v � �k��� r/�, 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio ntents were disposed: r L.S.D Lowo Waste Water �l Signatured6f Hhlej Date t5form4.doc- 06/03 System Pumping Recons • Page 1 of 1 Commonwealth of Massachusetts City/Town of W° System Pumping Record Form 4 41M SyOV`v AAO � W1 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of hous ht rear of house, right rear of house, left side City/Town left side of house, right side of house, Left ht rear of building, under deck. LA cP), Vj \ v\DV ac C�-"cl-�A�,� &v� State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record R'a2� k k 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Sta/�^` i Code �V Telephone Number — 2. Quantity Pumped eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: SIU txcN � 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Loqafiep�vftre contents were disposed: L.S.D. Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1