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HomeMy WebLinkAboutMiscellaneous - 76 OLYMPIC LANE 4/30/2018 (2)F7 DEP has prodded this tam for use by local Boards of Neagh .OvW fomes may be used. int wManon roust be saatarmew the am as oft prwA � 801g1r! � this tomn. c�►ecK with your but the Imal Board of Nem b b dsbemine the form Owue 7"he gviftwn PwnFW p Ra00rd must be submitted to the focal Board of Mob or other approving authority witkirt !4 days fiom #0 Pumping date in a000r+danos Wfth 310 CMR 15.351. A. Facility Information W4 vAbm 1. System y Location: on the aonyNRer. • t �, � use ody go pb �� w N°�1 PRzMosN1 key to mow your Addoees a key. the oetum C�Owll ,�.• keyj,� Code 2. System Owner. a4XNOW �1 , Rig AOM (if 0161rept ion bCdW) ci+yRawr, : zo coos TMptiorN �a+�r3— y�1a;�( S. Pumping Record 1. Date of Pumputp oea I Pumped: 3. Type of system: ❑ CesspooKs) Xseoic Tank ❑ TIN Tank ❑ Grease Trap D other (describe): 4. Effluent Tee Ft7tet present? ❑ Yes,X No {fy8s, was it leaned? (] Yes [j No 5. Condition of System: 6. System Pumped By: RofacZwrne e k s 7. Location where contents were disposed: 6CS*-n a� si�tur.awahrgFaa� tSbmMAW 03!06 &ISIM PW*j Record - Page i of i Commonwealth of Massachusetts City/Town of : SEs' ��13 System Pumping Record Form 4 r.` , 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 SyeWn Pumping Record must be submitted to the local Board of Health or other approving authority within 44 days from the pumping date in accordance with 310 CMR 15.351. A. Facility Information Important: When filling out fors 1. System Location: on the computer, use only the tab • -76 n !'1'1 i::) l C l h key to move your Address cursor - do not e A use the return C /Town key. hY State Zip Code 2. System Owner. Name nem Address (if different from location) City/Town State ' Zip Code s 7Z- 6.3 — ,i� �i Telephone Number B. Pumping Record /oay 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) "Septic Tank ' ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yerrt>10 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name _�O��CZ� Vehicle License Number Company 7. Location where contents were disposed: D Signature of Hauler Date Signature of Receiving Facility Date t5for4.doc• 03106 System Pumping Record - Page 1 of 1 TO W N 5Y37T—'N'1 PUMPINQ R -p DDREss SYSTEM• DATT OF p PUMP k3 Z)C) POO L; Npy 4 14A rvxb 0,v nV 14M K 8�� SIYB 8pl,lpg ....• ��CK�t�,4 KUNr3��•f•, P"00DRD ONER-eXPLAIN �.UNJ'tN)'y rA.�Njr tx &b 0 I't 01�1; T-4,11,71 -4 ')CV_R DEP ha p(ov v — T I I IdOd form f:)r Geo to,tocol — - - - I bo the local 6oarc Y E30arcv of HQBI�T cr n Q a,( n or o t ri � ( I I -'� 0 5 3 rn P aPP(o'ving autnor, Facility —In f �f�'a t I c) Spom Ownor, Q n) -- orcj Cate of Purn'ping% Typo 91 oyal: om; . 0 optic Tanx ) ,,� `lO;her (describe Effluo.V Too Flko(prow r? 7 Yo3 0 n'QM: . 141�7 1c, oX LOon where corllenls'wera disposed: r �ri 44", 1 Q1 H; v 4 1f Veanoo? L7 Ye5 Owls i TOWN OF NORTH ANDOVER.:'"'„'U`r SYSTEM PUMPING RECORD SYS'T'EM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) DA'I'S OF PUMPING: �% 112, QUANTITY PUMPED %f>DD GALLON'S CESSPOOL: NO ',Z YES SEPTIC TANK: NO YES _ Z NATURE OF SERVICE: ROUTINE ✓ EMERGENCY 013SERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: C'O:NINIENTS: CONTENTS TRANSFERRED TO: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) �._♦ c�,�i i . c:v... v JVVJ r Ja+V11 J I G'NHft. l / HI YLV�/GfT. rHVC qui I' N Atdt ANL1bver IR.4 r+,- 1--A6o,n .Cf. sMvu� N. �4 A n .�- 4 utQAo r "oil MR 01935 to c ,gSr 979-372-7471 !i G� fa� It 020 i _m AMR= My l5OL op NQS �� fes, d q6 t t3Qj All /015or Dim tc_ s .,r Imo' 1� �5 a? %t72 I Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protect! Wllllam F. Weld Governor Trudy Coxe SaerMat EA David B. Struhs Commissioner —BOARD OF HEALt n JUiv 141996 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: G 0 Address of Owner: Date of Inspection: / j' (if different) Name of Inspector: ��. ' d S14 - Company Name, Address and Telephone Number: ( ` L tt ©A0 �. �� fi .1-1 o6 u R v S4 7 �%•7/ CERTIFICATION STATEMENT /o�''' P`�x !/, 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: Date: /— The System InspectorZall bmit a copy of this inspection report to the Approving Authority within thirty (30) days of completing tins inspection. If the fystem 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. INSPECTION SUMMARY: Check A, B, C, or D: A] SYSTEM PASSES: I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteria not evaluated are indicated below. B] SYSTEM CONDITIONALLY PASSES: �// / One or more 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. (revised 8/15/95) One Winter Street a Boston, Massachusetts 02108 a FAX (617) 556-1048 a Telephone (617) 292-5500 %D Printed on Recycled Paper r is/' r,} SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION" (continued) Property Address: Owner: Date of Inspection: ,` G�► J B] SYSTEM CONDITIONALLY PASSES (continued) Sewage backup or breakout or high static dual 4level 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 C] FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: �/ A _ 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 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 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 APPROPRIATE) DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: _ The system has a septic tank and soil absorption system and is within 100 fee', to a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is within a Zone I of a public water supply well. The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and 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. D] SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined 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. (revised 8/15/95) Backup of sewage into facility or system component due to an overloaded or dogged 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. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: DJ SYSTEM FAILS (continued): Static liquid level in the distribuion ox 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 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 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: . 4 . The following criteria apply to largesystems9.4. in addition to the criteria above: The design floe of system is 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: 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 bring the system and facility into full compliance with the groundwater treatment program requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (revised 8/15/95) 3 N SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST G Property Address: Owner: R �� Date of Inspection: Check if t:�Pou'.O'-eng ng have been done: _ information was requested of the owner, occupant, and Board of Health. _ None the system components have been pumped for at least two weeks and the system has been receiving normal flow rates d ng that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �As,Kuilt 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. he 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. Theseptic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of baffles or lees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. X�_/T size and location of the Soil Absorption System on the site has been determined based on existing information or pproximated by non -intrusive methods. _ The facility o,�ncr (and occupants, if differen! from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 0 t�.yW �-/ Owner: e Date of Inspection: RESIDENTIAL: FLOW CONDITIONS Design flow:rtallo Number of bedrooms:? Number of current residents: Garbage grinder (yes or no):,T-7 / Laundry connected to system (yes or not: Seasonal use (yes or no):_ 1 Water meter readings, if available: Last date of occupancy: /I C—C• v� (r' COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: rtallons/day 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: PUMPING RECORDS and source of information: GENERAL INFORMATION -:r ..l e YS System pumped as part of inspection: (yes or no) If yes, volume pumpedI l,� alIons I& ? � Reason for pumping: I&It tto TYPE O�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) Other (explain) h ,9//,or vA APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) I/ (revised 8/15/95) . 1* SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner.: Date of Inspection: SEPTIC TANK:S (locate on site pl n) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: A % A- S' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness:y ' Distance from top of scum to top of outlet tee or baffle: � Distance from bottom of scum to bottom of outlet tee or baffle: / c ' 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.) GREASE TRAP:_ (locate on site plan) H4. Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Scum thickness. Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum tr, bottom of outlet tee or battle: 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 8/15/95) 6 r t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: f7 �G If 11�t�/G �j �'� ��`��G a Owner: Date of Inspection: e (• S`"- �� TIGHT OR HOLDING TANK:_ (locate on site plan) Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: gallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Yep S (locate on site plan) Depth of liquid level above outlet invert: 0 / Comments: V r (note if level and distributio^ i equa!, evidence of solids carryover, evidence of leakage into or out of box, etc.) Ma S'/G�, ct--�E",c T,.Z .a 7X -0%r r F� PUMP CHAMBER:_/ (locate on site plan) Pumps in working order:(yes or no) Comments: (note condition of pump chamber, condition of pumps and appurtenances, etc.) (revised 8/15/95) 7 t SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) ,���o��� Property Address: p Owner: C e3 Date of Inspection: of tk SOIL ABSORPTION SYSTEM (SAS):_y"P S (locate on site plan, if possible; excav tion not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: n leaching trenches, number,length: It elft e S'1 leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLSt _ I (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 ponding, condition of vegetation, etc.) 1 PRIVY: _ g 14. (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.) (revised 8/15/95) f SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' FAccf✓T 0. k, DEPTH TO GROUNDWATER n- Bo )4 our 0�' %Y/J Depth to groundwater: _E ?- feet method of determination or approximation: ",d 5Z Li'/' 4 (revised 8/15/95) 9 6-C, 011ie, B - G a7'9 C3-� 33 La t j. v y f r 4 a) 1 •'b `jFr54.4 rr�;a( 1} ��?x}'�},!,f.. l� y' ,j ,t ,�fI� r ,q• 'k h k� .'.�1+� r'"thi'�r ��'�L��••}+ttl�.. t/. 1i �� ,t ,} ?!: 1 1 fi.T, to • t , ! 7 � r +y7 (' ► f' +* Y t f t nq � ), J ,� t - � a i �, t , ,),.:i, lj„� , � � �y1 ,F�`' srrf'41 � �? � i`y,k}tr�,.,;p'r�ar � ^ � Q � 'k � � • �• .4' d r��•4 y I' �. �r �' :'ylrx (i { �{ ,,.£"�. ��r,>ffx /, f !•r'�4 r -1 it K i':.« 4' , , F. �tM.t�+ .�`r�i,�a.��7C:J t rf`"•r -f ,! l'A�:"•*f'''•T [ �Tt� (=•'n'� , ""0 aL� r A Sys lvm p �i1,JJ0`% 1�R UIVIFIN� RECORD �a f ,!r M: ) r.••� � 'i'1'r, .• i , t iii kF'�L L��'i /i Ma • ; x ,� t; � LAS.'; �..�.,:,,+t�n�°.'t�,:�.kryq+►$»sy�;t}t�''+ � .., , � 9 ,,�`'��'rT�h��r'�4� . y/ Z v .,, �i t�f ,1 r� 1. ,y « 1 ' .i• 5'1 . i l �r i.' .. • ..l�4. r.ti •4:.,'�, w+p' .".ri9� +- 1 .%+ � ° `e -P. �. tt n•�}�'��?. rY' Y � .. *' +« ' \�ti.J 1 P'L •�� �i�„1 , Q •� r! r.•r f1f1 Ft.«' Y., .. r„s'ra�? ► ;r.:.t. 4 ;iL WNEIt'ADDSSS ' ; SYSTEM LOCATION foot OtbO u”, Nlft''F�i�y1•,T ..fir, �. r 1 `M/�L�� , .�jyy.],y� , ;1 �”`;� �, � ��,�`•- .. Fill III '•Fr 1 1 a y+►'4 r'17\ t!`6 i�? ��ir""t yc P �'y;K d ING # UAN•I°ay PUMPED -� GALLONS �Qh�j�] � NOtI��^i{^ r '+'��� �� i•w )ri'l �'tFf Ilir '. . TANK: NO YES r/ ~� }f•�� ,, SHERGENCY 71,7 •1 ad , tv FULL TO COQ ; •.ROOTS: RAFFLES IN PLACE EXCESS SOLIDS L + QLD RGNBA CK SOLMS CAIMYOVIR FLOODEDTh �... PP'• c , Jt,�ti r , r�''Qq` rl;� ' �{(y�r �{ r 1 ?•beA.�^�1l4�•#.�r.:♦ In ,'4 r nvm:N,% .4 iiiiiiiiiiiiiijlll 111111,11 1!11111111�ililllllllllll 11111111 l�k �fNr ,Yh�'t r;�J;rld•�•F ��'1T?r ,s., 5 l.Rr r til ? 1 , r �' +4t fr.; # rx4' :�J r P `�'' • , . r f •, r y,�'i•�`�t't M r iiiiiiiiiiiiijilill S TT 7, r �a 4 �', t} t f •,�l, h'.�'a' iy.t'37yPr Sr r �f t AQ: � d +� t v A� t ,r r. j�tlf�.'i' '�.i a��l'1�,'f 4,„,yy��7,' �`} Y•�y�,� '�+r♦ , I P J SYSTEM OWNER k_ADDRESS TOWN OF NO .'Irli ANDOVEf.,. ,Sy',STEMjPUqPlNQ RECORD SYSTEM LOCAT10N L)ATE OF PLJMPIN(3:/ .._QUANTITY PUMPED:_ 'I CL'SSPOOL: NO___-._ . YES- ­_SOPtic Tank: NU NArUKE OF SERVICE: ROUTINE. -RG 0 b S F -R V A [TUNS: GOOD CONDITION V/PULL 1`0 COVER HEAVY 0R.&ASE BAFFLES IN PLACE ROOTS ­­_ LEACHMELD RUNBACK EXCESSIVE SOLIDS FLOODED SOLID CARRYOVER. _ __ OTHER EXPLAIN ...... SYstom Rumpcd by l'OMME,N'I'h RECEIVED OCT 0 5 2004 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT YES CUNILNI'S FKANSYhRRED 10 0 - //// // J_j_ I ro#.!}l..�y�:•[ats�.Vt U' . —. •� a;1,fe',:%.RD,�M;'�,��}t5+1A+h'.•,t�.�.1'Yt til':'I�Yyi:!+y`t'It.' `• ;c'ti` jj+n„ aJ K .,1i •1.1Y 1.Pil;''!'r.j+,��•i:Y�: �, 'W. QS ia.�r.!r'� ..:!•, :"!a:: �,.Ytv :�, h',+ a��lij(.'r1vP•: A: 'f�•, �; )�''. 1J':%Y'.%; r; .. ..;•,>,�, !tir;,:jf f..,y:, r.,w,.. '.1:! ",•:•u•.„•rt f'"Y,t.. , hill S' rov(ded �...,...•,:,�' A. this form for use by local Boards of Health. The System Pumping Recora m, --s: be subml4ed to the.local•Board of Health or o her a ;,• y,' pproving authority. . A: FaCIUty Infortt tion 5 2007 v,rYYhsn fiUln� Out .1.. System Location: only the tab key Address to move your ,.waw - do pot —ty/Town '• tui the, rotum :' Cl / .. Stat ';�.:•,:s: e Z1pCode °Y�,�.>,.�,:.s�::>.�'2 System owner;.,,' ' •�'i' \lam �„�: ,.a,r;f,.. •.:t':.~: rv% ' `•' '.,."+,!` `:Y' 'f't: '',;`r• Name • „', ,. , I'','. Address (If different from location),.... Cty/iown, Stat W. Telephone Number rj' + t Y , PumpLg Regord r' ' ��;. ,,;.•,l�;i.ge:�+.+Lw�•�::5;:,;;+����:;.:aT,;.illij'{i•ii.lt.it%%•, ,; ,, J ' , , ,•� , 1. Date of Pumping''Dale 2. Quantity Pumped: Gallons 3r: C ype Pf system; . ❑ esspools) �Septic Tank ❑ Tight Tank Q jOther (describe):'; Effiuent Tee Fll/te{present? ..❑ Yesyes, No If w d? C. .. , ;��., , as it cleane ❑ Yes—No aa1 :•>' , , Y• J•. y{ ., '•• t t 'T:” '• 1•.f 1(f .j;�`, •. ;•., ”"ry y+..,�. ', ,:11. :'f� y`T��14'Y ''•'r 'i.�. ... �l�/ M.r •., a � 7 .:':l' ' •i •'�'+f' Y � / / jar' •:'�.• :a'' •711'.;Y.'.�+1':�'!''�:�j.''+.jr,•ra'r•1 ���'l. t. yat IQMPump • .'l1.. : •. 5::.:':i I':'. 1 ed By. _.moi ':.: S. �.i,'•;�. ., �1• a �';'•1'i`Y�7.+ ,�r�l ', ..�Ji" t .1/ '�'I� �'t 'rVl �. 1y, i'.•. a Y ��r'i 7r Sy1,C!, ;'.1;,(t, 4F�',,� 'y'p'•+r}1 �.j i . ':.�;. 1 •� Y ri r' :•r't. a,w+i'i'''•''7r Ir•� ,v til; �� ��•�.�`1t.,1 4/w 5:r1r1 ::;Y.� .t,.•'•� ',' iyr,u 1 1"! � :�?,.'r�St�'{J,t':••vi�t'`:it 4; : Locaflon.whera contelits Were d1;3posed: ' %,'�I.T ';i C' �:' .t ;'`,� r.i�+ v�w •t�.%is �'�;.'i ;'1..''1.. :.. t.: r:p,..n,1.1:.n1: "' � .. f'...s:.'SlpnattueofHal uler, 1: httpJlwww,mass rgov/dep/waier/aps/Wormsrhtm#Inspect t5fWM.doa10&Q3 ; 1: Vehicle Ucen#e Number /1 Date Syttem Pumping Record • Paye 1 01 /ER:. MASS T7 0EP.hl 4 plovlded W4 loan f')t neo .oco1 80 DO (Q the loci, A. F a �—yl —nf C'a a() 00? 7 I m� - '- -' , i0 ,e"? , L w U on: TOWN OF NORTH ANDOVER -a HEALTH DEPARTMENT Hvni Of 9vi 111 MUM ----------- cloea Rekord oa,o Q'I Pum PI -91 P(!C Tat),, 7Isr.l lay, C'a a() 00? 7 I m� - '- -' , i0 ,e"? , FORM a - SYSTEM PU TLNG RECORD Commonwealth of Massachusetts /l,-4vDoUV- , Massachusetts S stem porn in Record er �yste ok1 ti �� u( 0,VC, �G o l ym rc- m v� CC f f COW et 21 (Qvt pee P a �0t:Hj4D0ErntjrHANC0)ovER 4 T EENT Type Emergency ❑ Routines' Cesspc �I: No Yes ❑ Septic Tank: No ❑ Yes ,. .❑ ntiry Pumped: �oc _ _ gallons Date c :' Pumpine: Qua^ BORACZEWS Permit .. Sestet:: Pumped by (Company): — - - Conic .ts transferred to: Cont..tt.s disposed at: � /- S jl D,, AZs�o Pumper Sienattire Con( Ilion of systernJothercomments: DE? APPROVED FORM • 0/07/9S S^ Sv tend tZll7 nine nrc,v� u ystem option ner C)��� f-(ovS'P 9 � , )�Oc)Ue� /Vo > Lq gg6c TOWN OF NORTH ANDOVER HEALTH DEPARTMENT T%,pe: Emergency C.J Routine ❑ S� tic Tank: No ❑ Yes Cessp( .)1: No ❑ Yes 11 P D�� Date c :' luantiry Pumped: _ gallons Pumpine. ,j$pRAGZEK ., Permit - S\,ster., Pumped by (Company): Contc .ts transferred to: Cont:.tts disposed at: hl,12 NC Dee( Pumper Signature Condition of system/other comments: 7ec$D DE9 AYPROVED F00.NS S:/0719S Commonwealth of Massachusetts W City/Town of Merrimac o System Pumping Record RECEIVED Form 4 99 DEP has provided this form for use by local Boards of Health. ther �?Lis2A �&JzIsed, ut the information must be substantially the same as that provided h e. Before usin&hio, check with our local Board of Health to determine the form they use. The Sys rrii'Q i t be submitted to the local Board of Health or other approving authority within 14to in accordance with 310 CMR 15.351. A. Facility Information Important: When _. filling out forms 1. System Location: on the computer, 1 use only the tab 6 1 y My 2 i' Y! key to move your Address cursor - do not/�%©• A r Jo (/ e use the return M§Raftw key. City/Town 2. System Owner: Name Warn Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Other (describe) Date ❑ Cesspool(s) MA State e Zip Code State Zip Code Telephone Number 2. Quantity Pumped: X[ Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes a No 5. Condition of System: 6. System Pumped By: Name BORACZEK'S SEPTIC & DRAIN IOOU Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number Company 7. Location where contents were disposed: GL -S 1) 6�j *" _ Signature of Hauler Date Signature of Receiving Facility t5form4.doc- 03/06 Date System Pumping Record • Page 1 of 1