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TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:,
7� f6p�-L1,1 .
(example: left front of house)
Jac L. -Z5�.
DATE OF PUMPING: ; - 7 y l QUANTITY PUMPED 1,50p p GALLONS
CESSPOOL: NO • YES SEPTIC TANK: NO YES
ATURE OF SERVICE:
ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
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COMMENTS:
2001
CONTENTS TRANSFERRED TO:
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Board of Health
North AnO__y2,lx ax S*
OK
BM>T-IC SISTEM
INSrALLATICK CHKK LIST
ISA2PROVED DATE
LOT
_LXr_VATIMOK M
1. Distance Tot'
a. Wetlands
b. Drains
2., Water Line Location
3. HPe
4. %Ptic Tank
a. -Tess - t --Length & To Clean Ont Covers
b. Cement Pipe - to Tank-- On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Eqiva Amounts
c. .o BackoWw,,
6. Leach Field or Trench
a. Dimensions
-b. Stone Depth
c Capped Ends
d: Clem Double Washed Stone'
7. Leach ME;
a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tess
e. Cement Pipe to Pit Both Sides.
f, Clean Doub'je Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection C
10. Barricading Covered System C
Z C/
3.1. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location Stith Regard -to Pere Test
d. Elevations
e.
Wa�ter able
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LO
TO: NORTH ANDOVER, MASS.A10 �� � �! 19
BOARD OF HEALTH J
FROM: DESIGN ENGINEER Re: Soil Absorption
Sewage Disposal
System
This is to certify that I have inspected the //construction materials of
%
said disposal system at Lo i 201q C -7✓ / to i7
Site Location
North Andover, Mass.
The grades and construction materials are as specified in my plans and
specifications dated , 19 and As -Built > z 191.
Reg. Prof . Engineers Rea - Sanitarian_
Board of Health
No;A�ndover,'Iass
SUMURFACE DISPOSAL DESICfiT CHECK LIST -.
LOT # _ /�� ���
APPROVED DATE__- DISAPPROVED DATE - - -
Provided: Reasons: `
Title FAIL CE _
Reg 2.5 The submitted plan must show as a minimum:
the lot to be served-area,dimensions lot #,abutters
location and log deep observation hoes -distance to ties
location and results percolation tests -distance to ties
design calculations do calculations showing required leaching area
location and dimensions of system -including reserve area
existing and proposed contours
g) location any r3t areas tithin loot of sewage disposal system or
disclaimer -check wetlands :napping
h) surface and subsurface drains within 1001 of sewage disposal
system or disclaimer
(i) location any drainage easements t$thin 100' of sere disposal
C rsystem or disclaimer-Plarining Board files
j)knows sources of cater supply within 2001 of sere disposal
system or disclaimer
location of ang proposed veil to serve lot -1001 from leaching facility
location of water lines on property -101 from leaching facility
location of benchmark
driveways
o -garbage disposals
no PVC to be used in construction
1-1 q) profile'of system -elevations of basement, plumb, pipe, septic tank,
distribution box inlets and outlets, distribution field piping and
✓other elevations _
c ) maximm ground water elevation in area sewage disposal system
(s) plan must be prepared by a Professional Engineer or other
professional authorized by lair to prepare such plans
Reg 6 Stpti_c Tanks
j(a) capacities -750% of flow, Crater table, tees, depth of tees,
access, pumping
cleanout
c) 101 from cellar gall or inground swimming pool -
(d) 25+ from subsurface drains
Reg 10.2
Reg 10.4
Distribution Boxes
slope greaterthan 0.08
MWIT
L -T
'C'\ Commonwealth of Massachusetts KECEIVEC
CitylTown of
mJUN 3 U 2010
System Pumping Record
TOWN OF NORTH ANDOVER
Form 4 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 tQ determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or oth6r approving authority.
A. Facility Information
I. S s ation: Left side of house, Right side of house, Left front of house, Right front of house,
Left rear of Right rear of house. Left rear of building. Right rear of building.
Address
Cityrrown
2. System Owner:
Name
Address (if different from location)
Cityrrown
State
B. Pumping Record 6-6-3-40
1. Date of Pumping
3. Type of system: ❑
❑ Other (describe):
Date
Cesspool(s)
4. Effluent Tee Filter present? ❑ Yes Leo
5. Con J04 -Sy
6. System Pumped By:
Neil Bateson
Name
Bateson Enterprises Inc
Company
7. Location where contents were disposed:
G.L.S.D Lowell Waste Water
Signature of Hauler
Zip Code
StateZip Code
l' 2s_ o3
Telephone Number
2. Quantity Pumped
eptic Tank
Gallons
❑ Tight Tank
If yes, was it cleaned? ❑ Yes ❑ No
S� As �� V_14�_z_
F582_1
Vehicle License Number
Date
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