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Miscellaneous - 75 GRANVILLE LANE 4/30/2018
Commonwealth of Massachusetts City/Town of System Pumping- Record Form 4 OCT 2 0 2014 v DEP has provided this form for use=by local Boards of Health. Other form �a l " iJ's kd l iit£tia �R ,� til a� h� ��� information must be substantially the same as that provided here. Before using= ' is I`orli c�ieciih your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility. Information 1. System Location: Left/ Right front of house, Left/ Right rear of house,2 ng i o hous , Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address city/Town 2. System Owner. Name Address Cd different from location) City/Town state W� � I 3 Zip Code j Code �:. Telephone Number 1 B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons —� 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yeas ET No if yes, was it cleaned? ❑ Yes ❑ No: 5. Condition 6. System Pumped By.- Nell. y: Neil. Bateson Name i Bateson Enterprises Inc Company 7. Locatiory�ere contents were disposed: F5821 Vehicle License Number Date t5fbrm4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts EIV- City/Town of System Pumping Record OCT 2p 3 Form 4 TOWN OF NORTH ANDOVER HEALTH D�pna-n A. ,_ DEP has provided this form for use>by local Boards of Health. Other forms may be us6U,-b information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left/ Right rear of house, righ I e . fhou , Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under eck Address Cityrrown 2. System Owner. ', — L Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code Statp,-) j de Telephone Number t /0- � k \3. Date 2. Quantity Pumped Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditio 0 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany where contents were disposed: t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 !C—\ Commonwealth of Massachusetts City/Town of System Pumping Record ` Form 4 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. qQ 711 DEC 0 3 2007 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. Systr Loc n Address e Citylrow n (� �-�� a State V 1 Zip Code 2. System Owner. Name Address (if different from location) Cityrrown State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): I � -a ( -6`7 Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Q446-- 5. Condit' of Syste� 6. Systeped By: 1 Name Company 7. Location !contents were sed: If yes, was it cleaned? ❑ Yes ❑ No t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 ARGEO PAUL CELLUCCI Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION TRUDY COX Secretai DAVID B. STRUE Commission Property Address: —7,5 E*aAK Vt+-L#_ Lo KC Name of Owner K oe,t,(� Ari flov t2 . M l address of Owner:_�� M P Date of Inspection: 1 b Name of Inspector: (Please Pdffi y t 3 Kk l7\��C 1 am a DEP approved.system`inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: MaNrgAddress: 34 Z � �GP Telephone Number:10 -AA7 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: _V4asses _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails hspector•s Signature: AW/ Date: l o ' " q q The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)widdn 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 finvirohmeMal Protection. The original should *be sent tovw system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page Iof11 ^ o,mn t — Rary W P.— SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: i-15 G2AN v►1.v_ Li W , Owner: w kWA4 K + Gb4 sTcN Date of kapecoon: k a • 14 " y q INSPECTION SUMMARY: Check A, B, C, o/ A A. SYSTEM PASSES: t-ko'(z:x 6k 4 "ov v& K �M I�kM 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: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Indicate yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. 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 pumpirig•tnore than fourtimes a yeartlue to broken or obstructed pipe(s). The system vaill Va. inspection if (with approval of the Board of Health), - -' broken pipe(s) are replaced obstruction is removed revised 9/2/98 Page 2orn SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: -7 5 G c -41KV % l.#-, Owner: W k►tL 4tA -h- Date Date of Inspection: No , 1 q _ qq C. FURTHER EVALUATION IS REQUIRED BY.THE BOARD OF HEALTH: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the public health, safety and the environment. 1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH. yaLLPRQTECT THE PUBLIC HEALTH.AND SAFETY AND THE ENVIRONMENL- _ 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. 2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: - - _ 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 feat 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 vafid).- 3) OTHER revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: "i,' GMK \ "4-c L Alae_ , ri o e -C 4 W t`tOd V V&, M 4 Owner: w � t ,_\ R M -t- Ghgk$, C IPU L -k 2.1,(2•M Ae-IN Date of Inspection: I a • l -q - 4 c( D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No Backup of -sewage inw4acilitywr-syatem componentduetto an overloaded orclogged-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 1/2 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 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. 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: 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 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•iewvitWa 200 feet of_Hifmt yAs_aeurfaowdrinking�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 infognation. revised 9/2/98 Page 4of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property address: 7 `7 G(2•QN V I t.J.-� Owner: W i"AA M i mit "-c tw v 5* kM km V Date of Inspection: L(') . kA cj y Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yep No _✓/ _ Pumping information was provided by the owner, occupant, or Board of Health. _ None of the systemsompoarnts ham&Jnsn puammd4or-atJeast two weNw and-tbe-rystsm h"AmODwceitriPgOmMal.flow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this 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 orrthe 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) [15.302(3)(b)] _ _ The facility ownar-land-^^.... upants.if diftaraW Irnm-owner),wars.provided with iufocmatiomon f - SubSurface Disposal Systems. F1 revised 9/2/98 Page 5of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property address: '75 Gkwtw\uc Lqtie, NO1 Z Vl PrK00vexS Owner: W�wAA-Vj - t kAV-"-NlfktA" Date of Inspection: t (3 - l 4c , Ci C� FLOW CONDITIONS RESIDENTIAL: Design flow: (90 g.p.d./bedrckom. Number of bedrooms (design): Number of bedrooms (actual): Total DESIGN flow. i',0 00 Number of current residents: 'Z Garbage grinder (yes or no): S Laundry (separate system) (yes or no): N0; If yes, separafeinspection, required Laundry system inspected lyes or no) Seasonal use (yes or no)-._j!!O t q,1-1 -t k.1 -(,b % 00 O y -7-to Water meter readings, if available (last two year's usage (gpd): Sump Pump (yes or no): Y1&5 Last date of occupancy: 0 Gt:u PkWiD COMMERCIAL/INDUSTRIAL: Type of establishment: Design flow: apd ( Based on 15.203) Basis of design flow Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: lyes 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: sxa t{ -r o w V4,0-49, - LA ,, r System pumped as part of inspection: (yes or no) t40 If yes, volume pumped: gallons Reason for pumping: TYPE F SYSTEM Septic tank/distribution box/soil absorption system Single cesspool Overflow cesspool Privy Shared system (yes or no) (if yes, attach previous inspection records, if any) I/A Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other 2Z- R , a. r4 . APPROXIMATE AGE of all components, date installed -{if -known) -and sourseafinfermation: —•--�- Sewage odors detected when arriving at the site: (yes or no) KO revised 9/2/98 Page 6of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: -757 G�vt.t:c- — L4v4r- , Noe. -to A g4ovf , MA Owner: W uLA t (SNI, -,- Ng9AM AptM Date of Inspection: \ 0 - to . q cf BUILDING SEWER: (Locate on site plan) K Depth below grade:(Z• Material of construction: V cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line Diameter `r Comments: (Spndition of joints, venting, evidence offeakege-eetc.) Aff AQ ma CogOt-ttort . No S46w., of i & '( - SEPTIC TANK: ✓� (locate on site plan) Depth below grade, Art G(44'0a� Material of construction: �oncrete _metal _Fiberglass _Polyethylene _other(explain) If tank is Intal, list age _ Js -age -confirmed -by Certificate of Compliance _ (Yes/No) Dimensions* Q-O� t+L 5 lO'� Sludge depth: t '' V4 Distance from top of sludge to bottom of outlet teeorbaffle: Scum thickness: 0 - i X14 Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: t 9 How dimensions were determined: M e -A -Qu (WJ- 9-16V( Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles, depth of liquid evidence -off llela�kage, etc.) _ , 77- 13 Z A, ,a 4 • O Z 1^ 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: in relation to outlet invert, 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 7of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) �l Property Address: 5 GO -ATI Vttl Q, �,f�rN (?. t c�2G�E A OV Q {� ` �1iI Owner: Date of Inspection: k o- k A .4 q 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_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: r Comments: In �a if level and distribution is equal, evidenee of solids carryover, evidence of leakage into or out of box, etc.) - ' — U�S4iRif3�-t�orC cs , %Ao Sk&R c3(= CAf�AVo40AoeGoLx4S+ a+s�GK PUMP CHAMBER:_ (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) revised 9/2/95 Page 9of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 713 &0-4. t-twt .uv— LAt t e- I V{of'zjj AK ooveV % Mfg Owner: W % I -L -k 4 M A- Data of Inspection: I �9 , � SOIL ABSORPTION SYSTEM (SAS):_ (locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leaching pits, number:_ leaching chambers, number:_ ' leaching galleries, number:_ leaching trenches, number, length: dT4� leaching fields, number, dimensions: a.: K CIA. overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, daTp soil, condition of vege ation, etc.) Ko �6�tS n Cr- 'A%t 04 A V" C, Ff '-wev , t'ore�Ll�Kb a RM4 GaL- d 0— CESSPOOLS: _ (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 (cesspool must be pumped as part of inspection) Comments: (note condition of soil, signs of hydraulic failure, level of .pending, condition of.vegetation, etc.) - PRM(: _ (locate on site plan) Materjals 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 PART C SYSTEM INFORMATION (continued) Property, Addraw: `t GtLt4rW,�.►.� LsityV- k \NWZ:ttt (�Vlbov 04, MA Owner: W t.L�tA�e1 �- CARAc,-t%KC M-\o,gmtA1-*A1,A Date of Inspection: b . «•qo1 SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) A • F�2oNY ig�.� dP N�u� Q - ftv's . Cv �F k4 r— To SzVjkC- \i1µK - (N-WEC ,,0 S- e \SX RA SOI At YZI©K o (,845 0 S f—,Mc, ' uQUAcJE k\ &) ox — tOWNk x Ct �Acb1 �rL.G- �-� N P -S - S o� t.d �►.G-� revised 9/2/98 Page 10 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: IS Gav% u_c 1.PtKe_� TCt PO Aioovez_ l MA Owner: Vu M-11 + CA (2_' 9 -R -M (or,L*4 Date of Inspection: � 10 - �A . q q NRCS Report name Soil Type_ Typical depth to groundwater. USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep _ SITE EXAM Slope Surface water Check Cellar Shallow wells Estimated Depth to Groundwater % Feet Please indicate all the methods used to determine High Groundwater Elevation: ti S'o • }l P�� - �z Nc�� # t C►+- Zo .-7�� �� w►�-e T� 7 -� v Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) 22 ¢ , Determined from local conditions W 0�'� V4vsi �-1 urs' -0 ft's, (�@ A11 �5_�u4 W 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) © �3 ,o.kA eLtok - - $-1\•Z7 n F S(.)N1Q QV'i�-c tvkc revised 9/2/98 Page 11 of 11 Commonwealth.. of Massachusetts City/Town of System Pumping Record Form 4 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 filling out 1. System Lo tion: forms on the C. computer, use only the tab key Address�CA���"' `rl c move your P �� cursor - do riot �'v \ a use the return Cityfrown State Zip Code key. 2. System Owner: Name SijnituA of 14auterl Date System Pumping Record • Page 1 of 1 El� Commonwealth of Massachusetts ND City/Town of No. Andover 05 a System Pumping Record WN OVER a°^ Form 4 T M DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 8/11/05 Date Cesspools) 4. Effluent Tee Filter present? ❑ Yes 19 No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: Hauler MA State State Telephone Number — 2. Quantity Pumped Septic Tank 01845 Zip Code Zip Code 1000 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 8/11/05 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: forms on the computer, use 75 Granville Lane only the tab key Address to move your No. Andover cursor - do not use the return City/Town key. 2 System Owner: QElaine Manke Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 8/11/05 Date Cesspools) 4. Effluent Tee Filter present? ❑ Yes 19 No 5. Condition of System: 6. System Pumped By: Benjamin Shute Name J's Septic & Drain Company 7. Location where contents were disposed: Hauler MA State State Telephone Number — 2. Quantity Pumped Septic Tank 01845 Zip Code Zip Code 1000 Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No H79 406 Vehicle License Number 8/11/05 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 FORM 4 - SYSMI PLWING RECORD Commonweafth of Mass"huse& r Massachusetts Systen Pwnzing.Record Type: Emergency D Routine C Cesspool: No Yes Q Septic Tank: No ❑ Yes E Date of Pumping:!/_y,? Quantity Pumped: _ /QQ gallons System Pumped by (Company): c vLPermit: Contents transferred to: .Contents disposed at: Date Pumper Sig w tue ' Condition of systemiother comments:/� / (�dniV An�i!'i� n r� y DEPA %GVFDF08M-ZY/0 M FORM 4 -SYSTEM pUllll iG RECORD Commonwealth of Massachusetts , Massachusetts ,S stem pumging.Record ystem ocation vstem Owner 75 Ae, CT ` 9 2001 T`, e: " Emergency ❑ Routine VJ P No ❑ Yes Yes ❑ S(,ptic Tank: Cesspool: I gallons Quantinl Pumped: l Date of Pumping: PC- Permit S% -stem Pumped by (Company): Contents transferred to: Contents disposed at: / i p,tz� Pumper Signature Condition of syslem/other.comrnents: DEP APPROVED POR.It - 0107195 Commonw alth of Massachusetts P. , Massachusetts System Pumping Record System Owner Date of Pumping: r D 3-c?q Cesspool: No L; Yes Ll System Location q _!�— 6fOMA-A 0-0—. Quantity Pumped: C W& gallons Septic Tank: No Ll Yes LAY. System Pumped by: Fd rej rt Srl&,tined License # Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner WON\V\ Date of Pumping: '-9 1 Cesspool: No Yes ❑ System Location 61))�u r, q-( Quantity Pumped: (1009 gallons Septic Tank: No ❑ Yes System Pumped by: &&&W 4idailijw License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TO: I ;•T NORTH ANDOVER, MASS d=�q /J' 19 7 BOARD OF HEALTH DESIGN ENGINEER Re: Soil Absorption Sewage System Inspection This is to certify that I have inspected the construction of the said disposal system at G % -,5— �,'•—le4IVV/1/,—= 44 North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 . At s eg. �)a7iarlan zzv !J -17P NO Te Ali ,y9 7/1 / I / Z, 10 1 ,�0��'� 1 g SA,vO/,S!p Cl) to /C)OO NORTH ANDOVE Proo; U ed v -4c. -s 1) Z„.# 3 V- .4- be( aJ SUBSURFACE DISPOSAL SYSTEM CHECK LIST I. General Information Reg. 2.5 The submitted plan must show as a minimum: the lot to be served �i location and dimensions of the system (including t"Ifeserve area) (0esign calculations (0 calculations showing required le_c arCD �� G (e) existing and proposed contours (6 k✓location and log of deep observation.holes - distance to ties location and _results of percolation tests - (distance to ties -location of any wet areas within . 100'._ of the 10 �wef� caj sewage disposal-- system -or disclaimer w �`t�%, �, 1001 "'�'U 6e �,,*dPd ( surface and subsur-face drains within 100of C7v-t• the sewage disposal system or disclaimer f� location of any -drainage easements.within VV"" 100' of the sewage disposal system or disclaimer (6 mown sources of water supply within 200' of Vthe sewage disposal system or disclaimer ( 'location of any -proposed well to serve the lot 2(( location of water lines on the property C maximum ground water elevation in the area of the sewage disposal system.,. no Co+r'tZPLAV1 0 � ( a profile of the system Val. it Gic E'S���S�''�f� A ho PVC -is to beused-in-constructioc(q 0-locati-on _of benchmark (r) , plan must-be-prepared_by a Professional Engineer or other professional authorized -by law -to prepareY)L= e such plans. II. Garbaq-e Disposers6� IV. Pumps .4 Reg. 9.1 (a) Approval Reg. 9.6 ib) Stand-by power �J III. 5ePtic. -Tanks- Reg: -6.1 (a) Capacities - apacities- Reg: -,6.7- Reg.-,6.7- - (b) --Water table Reg: 6.8_ (c) Tees Reg. 6.9: (d) Depth of tees Reg: 6.12 (e) Access Reg. 6.18 (f) Pumping IV. Pumps .4 Reg. 9.1 (a) Approval Reg. 9.6 ib) Stand-by power �J V. Distribution Boxes Reg. 10.2 (a) Slope greater than 0.08U Reg. 10.4 (b) Sump VI. Leachina Pits Leaching pits are preferred where the installation is possible. Reg- 11.2 (a). Calculations of leaching area -(minimum -500 S.F.) Reg. 11.4 (b) Spacing Reg. 11.10 (c) Surface drainage 2% Reg. 11.11 (d) Cover material VII. Leaching Fields Reg. 15.1 (a) Greater than 20 minutes/i:,c Reg. 15.1 (b) Area (minimum -.900 S.F.) Reg. 15.4 (c) Construction of field (��'�/�t Reg. 15.8 (d) Surface drainage 2% IX. Downhill Slope (a) Slope y/x = (to be shown) (b) y/x X 150 = (to be shown)O S Ic Benchmark Elevation SOIL PROFILE & PERCOLATION TEST DATA Town/City No. treetLot No. .� Loc . / Subdiv - %-,.�y `/ L- ' Plan Owner__z Investigator_7Cj& //_dObserver SOIL PROFILES -DATE 1' Elev. ?' Elev._ Elev._ 4'Elev. 0 00 0 2 3 4 5 R VA L-1 9 I0 2 3 4 5 6 7 1 M I0 1 Location Datum Percolation Tests -Date 2 3 4 5 6 71 91 I0 1 Pit Number 1 2 3 4 5 Start Saturation Soak -Mins. Start Test -Time Dro of 3" -Time Dro of 6" -Time Mins.lst 3"Dro Mins . 2nd 3"Dro TT- 1 _ _ 0%cL-c11e5 on bac r :nak C. Gelinas & Associates., North And. 1�7z 1 r- , , - I I . . ", : . � �*§7�4",�� 1 1 . � ,. - I - - . A , . . - 11 , , I I .. �1. I I I I . . , Nl� . - . I., I I - 1-1 I- I .. I I 11 � - �l I � . 1. LI� , �N I ,, - e , - �, , , � . : .. � . �-.'� - 1. I ��) . , . 4�", , - - .- I . � , I Ii- .... �, I ., . . , .. , , . -�. � . � - . , I �l rit" I - - 1. , , . I, ". � I �.. . I 11 . . :1 I I I I . .. 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LU LU41 QQ Q A V k W �i Commonwealth of Massachusetts City/Town of RECEIVED System Pumping Record Form 4 NOV 2 5 2008 DEP has provided this form for use by local Boards of Healtq.i 'Lf i#) Aeff e' but the information must be substantially the same as that provided he=Beft7'ie uvP1 MIS 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. 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locati o contents were disposed: 7. L. Lowell Waste Water re of F 5821 Vehicle License Number U-- C (`Y1 .- Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 A. Facility Information Important: When filling out 1. System Location: Left front, left r r, left side of house Right front, right rear, right side of house. forms on the computer, use only the tab key to move Address'-- LeA, r your cursor - do not use the return City/Town State Zip Code key. 2 System Owner: `- — Name Address (if different from location) 11 City/Town State ` S�Zi�o�d�e Telephone Number B. Pumping Record 2t-ca�� jam, 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Q Cesspool(s) V eptic Tank 8 Tight Tank Q Other (describe): 4. Effluent Tee Filter present? [I Yes No If yes, was it cleaned? p Yes No 5. Conditi' on orf jS� tem- 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locati o contents were disposed: 7. L. Lowell Waste Water re of F 5821 Vehicle License Number U-- C (`Y1 .- Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 'C'\ Commonwealth of Massachusetts RECEIVED City/Town of System Pumping Record SEP 29 2010 Form 4 TOWN OF NORTH ANDOVER �M HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Ot the information must be, substantially the same as that provided here. Before using this form, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health of ottxer.approving authority. A. Facility Information 1. System Location�oouse. ight side of house, Left front of house, Right front of house, Left rear of house, RighLeft rear of building. Right rear of building. Address City/Town State 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code State Zi Telephone Number (D(- l q --f C) Date 2. Quantity Pumped Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes R NO If yes, was it cleaned? ❑ Yes ❑ No 5. Conditi f of�Sy k�'�A tm (. U�x 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. LocgbWw4*r contents were disposed: G.L.S.D Signature F5821 Vehicle License Number Date 9 _tLl_�6 t5form4.doc• 06/03 System Pumping Record . Page 1 of 1 'C'-\ Commonwealth of Massachusetts City/Town of F.tffhid VED System Pumping Record 0 2009 Form 4 N -TOONTH ANDOVER ARTMENT DEP has provided this form for use by local Boards of Hes-raaay sed, but the information must be, substantially the same as that providusing this form, check with your local Board of Health tQ 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: eftsi �, fight side of house, Left front of house, Right front of house, Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address U \ �G� ` I City/Town State Zip Code 2. System Owner: Name Address (if different from location) Cityrrown B. Pumping Record Stat ZIP Code Telephone Number 1. Date of Pumping Quantity Pumped Date 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Other (describe): Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [ 1 o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: V-\,c)v 6. System Pumped By: Neil Bateson Name Bateson EnterDrises Inc Company 7. Location Ike i� contents were disposed: Lowell Waste Water Signature of Hauler F5821 Vehicle License Number --a-3 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of RECEIVED a System Pumping Record ,M Form 4 SEP 2U N11 DEP has provided this form for use by local Boards of Health. Other fr��" information must be substantially the same as that provided here. Bef Asan with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of house, right side of house, Left rear of house, right rear of house, left side of building, right rear of building, under deck. City/Town State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State- ��5SZ_ip Code Telephone Number R -� -3-\ � Date 2. Quantity Pumped Cesspool(s) eptic Tank to�:-t) Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes ZNo If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: Q� i A c 6. System Pumped By: Neil J. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc. Company 7. Locati where contents were disposed: �.L.S.D. Owell W ste ater d _ 1 Date t3— V t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of MassachusettsR��D City/Town of System Pumping Record OCT 20 2012 Form 4 M TOWN 0F NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form'for use by local Boards of Health. Othe lul I Im may De use , out Ce 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. t5form4.doc• 06/03 A. Facility Information 1. System Location: Left / Right front of house, Left / Right rear of house<oNgh ' e of house Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address Cityrrown 2. System Owner. Name Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ State Zip Code Stata5e Code Telephone Number Date 2. Quantity Pumped; Cesspool(s) eptic Tank Gallons ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes a No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of�Sy$tem: � ��� �� � A " 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio , re contents were disposed: G. L S. Lowell Waste Water It Date System Pumping Record • Page 1 of 1