HomeMy WebLinkAboutMiscellaneous - 777 JOHNSON STREET 4/30/2018rt
r Andover Boarh of Assessors Public Access
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Toven of Wo th Andover
Board of Assessors
Parcel ID: 210/107.A-0069-0000.0
SKETCH
Property
L Record Card
Community: North Andover
PHOTO
No Picture
Available
Location: 777 JOHNSON STREET
Owner Name: KENNEDY, JOSEPH A
C/O BILL APPLETON
Owner Address: 815 JOHNSON STREET
City: NORTH ANDOVER State: MA ZIP: 01845
Neighborhood: 7 - 7 Land Area: 1.02 acres
Use Code: 130 - RES -DEV -LAND Total Finished Area: 0 saft
ASSESSMENTS CURRENT YEAR PREVIOUS YEAR
Total Value: 236,700 215,300
Building Value: 0 0
Land Value: 236,700 215,300
Market Land Value: 236,700
Chanter Land Value:
LATEST SALE
Sale Price: 120,000 Sale Date: 06/22/1981
Arms Length Sale Code: Y -YES -VALID Grantor: GUNDAL ROBERT K
Cert Doc: Book: 01513 Page: 0047
http://csc-ma.us/NandoverPubAcc/j sp/Home. j sp?Page=3 &Linkld=991487
8/7/2007
DelleChiaie, Pamela
From: DelleChiaie, Pamela
Sent: Monday, January 26, 2009 2:43 PM
To: 'cmet78@hotmail.com'
Subject: FW: 777 Johnson Street - Septic Information
Attachments: SKMBT_60009012615250.pdf
To: Christina:
Attached is the septic information you requested last week re: the above property.
Pamela DelleChiaie
Health Department Assistant
Town of North Andover
978.688.9540 - Phone
978.688.8476 - Fax
From: noreply@yourcopier.com [mai Ito:noreply@yourcopier.com]
Sent: Monday, January 26, 2009 3:26 PM
To: DelleChiaie, Pamela
Subject: 777 Johnson Street - Septic Information
Grant, Michele
To: cmet78@hotmail.com
Subject: RE: 777 Johnson Street - Septic Information
Hi Christina,
I just went through your file. Your Septic System was built for a 4 bedroom or a 9 room home. The tank size
does not dictate. If you would like more information, please give a call at...... 978-688-9540.
Thank you
Michele E. Grant
Health Officer
North Andover
From: DelleChiaie, Pamela
Sent: Tuesday, January 27, 2009 8:53 AM
To: Sawyer, Susan; Grant, Michele
Subject: FW: 777 Johnson Street - Septic Information
Hi,
Can one of you help me answer this woman's question? I have the file at my desk. Thank you. O
P
Pamela DelleChiaie
Health Department Assistant
Town of North Andover
978.688.9540 - Phone
978.688.8476 - Fax
From: Christina Urquhart [mailto:cmet78@hotmail.com]
Sent: Monday, January 26, 2009 4:43 PM
To: DelleChiaie, Pamela
Subject: RE: 777 Johnson Street - Septic Information
Pamela
I see in the report that the tank for this address is 1,000 gal. for 4 bedrooms. What is the appropriate
size for a 5-6 bedroom house in the event that we wanted to add bedrooms to the existing structure?
Thank you for your time.
Best regards,
Christina Dennis
Subject: FW: 777 Johnson Street - Septic Information
Date: Mon, 26 ]an 2009 14:43:15 -0500
From: ndellech@townofnorthandover.com
To: cmet78@)hotmail.com
To: Christina:
Attached is the septic information you requested last week re: the above property.
Pamela DelleChiaie
Health Department Assistant
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C7
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
-D
AUG 2 7 2007
�\r THA ANDOVER
TITL TENS , i- C>! PARTMENT
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESS ENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: ✓l5 U yl 5' j"
,N. ��d o V - f 5 -j -
Owner's Name: i– L &8 s
Owner's Address: '-p(, 41 ,AJ
Date of Inspection: — D
Name of Inspector: (Please print) Qk ny I es J7 R o we
Company Name: Tewin 6u-ru Sewcar, Ce-yyier
Mailing Address: g16 Ph44,--N Rd .
Telephone Number: (2 74) o - 25tR Y
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: Date: g —9
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)
PropertyAddress:
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E/ ALWAYS complete all of Section D
A. System Passes:
J—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 exists. Any failure criteria not evaluated are indicated below.
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 nk (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank f lure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as appro ed by the Board of Health.
*A metal septic tank will pass inspection if it is structurally so nd, 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 'gh static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or unev distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipe(s) e replaced
obstruction is moved
distribution b x is leveled or replaced
ND explain:
The system required pumping more n 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Boa of Health):
ND explain:
!(s) are replaced
is removed
2
Page 3 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
PropertyAddress: -� I� 01) h h 5 a) L) 1
Owner:
Date of Inspection:
C. Further Evaluation is required by the Board of Health:
Conditions exist which require further evaluation by the B3/rd 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 accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will pr tect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surfaceater
Cesspool or privy is within 50 feet of a border' g vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Sopplier, if any) determines that the
system is functioning in a manner that protects the public heal, 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 s "
_ The system has a septic tank and SAS and the SAS is ) bithin a Zone I of a public water supply.
The system has a septic tank and SAS and the SASJA within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the S* is less than 100 feet but 50 feet or more from a
private water supply well** Method used to deternifne distance
**This system passes if the well water analysis, p formed at a DEP certified laboratory, for coliform
bacteria and volatile organic compounds indicat s that the well is free from pollution from that facility and
the presence of ammonia nitrogen and nitrate n#rogen is equal to or less than 5 ppm, provided that no other
failure criteria are triggered. A copy of the anaVysis 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)
PropertyAddress: I I �] �X< Z11l5 m `+
Owner:
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
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or
clogged SAS or cesspool
t� Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or
cesspool
i� 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 SAS, cesspool or privy is below high ground 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 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. [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 that 5 ppm, provided that no other failure criteria
are triggered. A copy of the analysis must be attached to this form.]
tJ 0 (Yes/No) The system fails. I have determined that one or more of the above failure criteria exists as
described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of
Health to determine what will be necessary to correct the failure.
E. Large Systems:
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of the following
(The following criteria apply to large systems in addition tot criteria above)
yes no
the system is within 400 feet of a surface d/king water supply
the system is within 200 feet of a tributafy to a surface drinking water supply
the system is located in a nitrogen se itive area (Interim Wellhead Protection Area - IWPA) or a mapped
Zone II of a public water supply we
If you have answered "yes" to any question i Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system h 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 contacf 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: :11 -1 �6� A5 &A,
Owner:
Date of Inspection:
Check if the following have been done. You must indicate "yes" or "no" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health
V Were any of the system components pumped out in the previous two weeks?
-LZ _ 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?
L/ _ Were as built plans of the system obtained and examined? (If they were not available note a N/A
4,Z _ Was the facility or dwelling inspected for signs of sewage back up?
f� _ 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 determined based on:
Js 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) [310 CMR 15.302(3)(b)]
Page 6 of 11'
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address:
Owner:
Date of Inspection:
FLOW CONDITIONS
RESIDENTIAL ���„
Number of bedrooms (design): SIA Number of bedrooms (actual): , '1140
` 1 %
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): y 0 GP( jib" SS
Number of current residents:
Does residence have a garbag grinder (yes or no): l�
Is laundry on a separate sewage system or no): &L—[if yes separate inspection required]
Laundry system inspected ( es or no):
Seasonal use: (yes or no): l _ I
Water meter readings, if available (last 2 years usage (gpd)) �Q e �lGt �l i�"� i�b►111PUf
Sump pump (yes or no): _J& L
Last date of occupancyc Jk f Ye
COMMERCIAL /INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.2
Basis of design flow (seats/persons/
Grease trap present (yes or no):
Industrial waste holding tank pres r
Non -sanitary waste discharged t th
Water meter readings, if availab e: _
Last date of occupancy/use:
OTHER (describe):
gpd
(yes or no):
Title 5 system (yes or no):
GENERAL INFORMATION
Pumping Records
Source of information:
Was system pumped as part of the inspection (yes or no):
If yes, volume pumped: gallons -- How was quantity pumped determined?
Reason for pumping: IU
TYPE OF 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)
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:
Were sewage odors detected when arriving at the site (yes or no): 14
6
Page 7 of 11'
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: -� I I � AWk +
Owner:
Date of Inspection:
BUILDING SEWER (locate on site plan)
Depth below grade: `
Material of construction: cast iron 40 PVC other (explain):
Distance from private water supply well or suction line: k)
Comments (on condition of joints, venting, evidence of leakage, etc.):
V .4
SEPTIC TANK: / (locate on site plan)
Depth below grade: Z X> L—Ol IZ � S e '-
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: ( (-90 Cj
Sludge depth:
Distance from top of sludge to bottom of outlet tee or baffle:' Z
Scum thickness:,
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto of utlet to or paffle: ,I
How were dimensions determined: I " Y -f'
Comments (on pumping recommendations, Ret and outlet tee or baffle condition, structural integrity, liquid levels
GREASE TRAP: (locate on site plan)
Depth below grade:
Material of construction: concrete
(explain):
Dimension:
metal
Scum thickness:
Distance from top of scum to top of outlet tee or b
Distance from bottom of scum to bottom of outlet
Date of last pumping:
Comments (on pumping recommendations, inl
as related to outlet invert, evidence of leakage, tc
_ fiberglass polyethylene other
or baffle:
and outlet tee or baffle condition, structural integrity, liquid levels
7
Page 8 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: —� � / J - yl, 5 '� Y� J
Owner:
Date of Inspection:
TIGHT or HOLDING TANK: (Tank must be pumped at
Depth below grade:
Material of construction: concrete metal fiberglas4
Dimensions:
Capacity: gallons
Design Flow: gallons/day
Alarm present (yes or no):
Alarm level: Alarm in working order (yes or
Date of last pumping:
Comments (condition of alarm and float switches, e
inspection) (locate on site plan)
! polyethylene other (explain):
DISTRIBUTION BOX: V1 (If present must be opened) (locate on site plan)
t
Depth of liquid level above outlet invert: Z
Comments (note if box is level and distributio to outlets equal, any evidence of solids carryover, any evidence of
leakag to or out of box, etc):
— � k5 1.P %/-P- i d--,, ,4x les -eye A P16w --a- -o Lj �l e �► ►� e5
Iiqa
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, coition 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: :�] :) I "Td �1)n 50)1 S E -
Owner:
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS): - (locate on site plan, excavation not required)
If SAS not located explain why:
Type
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length:
/ leaching fields, number, dimensions: C2 n X %40 se>o
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,
r
CESSPOOLS: (cesspool must be pumped as part of inspection) (locate on site plan)
Number and configuration:
Depth - top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater inflow (yes or no):
Comments (note condition of soil, signs of hydrau(
PRIVY: _ (locate on site plan)
Materials of construction:
Dimensions:
failure, level of ponding, condition of vegetation, etc.):
Depth of solids:
Comments (note condition of soil, signs of hydra is failure, level of ponding, condition of vegetation, etc):
9
Page 10 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address:
Owner:
Date of Inspection:
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. C
P'?� ZtA
L) 0x
36°
C-
10
9�
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
t3'
Prop er Address:
Owner:
Date of Inspection:
SITE EXAM
Slope
Surface water
Check cellar
Shallow wells
Estimated depth to ground water +1 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:
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:
11
RECEIVED
FOWN, OF N0,RTIJ AMYOOVI�,R
gYMNA Pljfl'JN0 Rl.,,O.Wk'
DAP AUG 0 9 2004
QLD NaaVEa
vF"m 0MIN!:-,.R & ADDRESSISYS' E KM I.,O(.-,'A'l I ()Ni D9EEPARTMENT
A in f
"0
Ivof
DAVE (W PU MWI NO Q11ANTITYPIMPEO,
NAMHEOFSERVICF. ROI.YFINH
OBSERVA FIC)N6- 11
(it WD OANMITION Lam' Al. TO COVER
11 F.A V Y k a R 1:,A S 1,. 8AFFLES, UN Pt,ACI.,
RMTS 1EACHMULD RUNBACK
il*N("fl.'SSIVI-"S(,)I"Ill.)� FLOODED
S01 -1f) C A RR YOV ER OTHER F,NPLAIN
2
COM Nl I "N(TY,
(AMEN US FRANNIMED P, 4
Ly
CHARLES ROUX
213 Patten Rd.
Tewksbury, MA 01876
Phone 978 640-9984
Fax 978 858-0590
Septic Inspections 8. Repairs
TOWN OF NqRTH ANDOVER
SYSTEM PUMPING RECORD
DATE
SYSTEM OWNER & ADDRESS
} enne_d
777 -7-oLsms/
IVOM') O/V,00 VeK, ly)q
RECEIVED
AUG 0 9 2004
SYSTEM LOCATION I HEALTH DEPARTMENT
DATE OF PUMPING:___77:g_!2�4__QUANTITY PUMPED:
CESSPOOL: NO Septic Tank: NO
NATURE OF SERVICE.- ROUTINE— I-- 'EMERGENCY
OBSERVATIONS:
GOOD CONDITION �FULL To COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER__ OTHER EXPLAIN
System Pumped by
COMMENTS:
CONTENTS TRANSFERRED TO C2,9
YES &"'�
Board of Health
North An.doveriN.aas.
%PPRCYVEDDATE
Z45
r RC-F���
SEPTIC STSTEH
INSTALLATICK CHECK LIST
ea sons i
pw� *60
x AVATIC�J Og FAIL
9 nP 5y5 -r&1,?- w4,5 _��
1. Distance Toi a� _�� OA /VP JWK'� wOUX'� l(
a. wetlands RIO, �EPi� �-// 5,4k/)tIOn)p /N )W(- �►�
b. Drains
c.. well "'�
2. Water Line Location
3. No PPC Pipe �v �J �1nC� EVOVMAJ OC&U'l%
4. Septic Tank
a. Tess -_Length & To Clean Out Covers.
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines.Flowing Equal Amounts
c. No Back Flow
6. - Leach Field or Trench
a.
Dimensions
b.
Stone Depth—
a..
Capped Ends
d.
Clean Double' Washed Stone
7. Leach Pits
a.
Dimensions
b.
Stone Depth
c.
Splash Pads
d.
Tees
e.
Cement Pipe to Pit -'Both Sides
f.
Clean Double gashed Stone
8. No Garbage Disposal
9. -Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard -to Pere Test
d. Elevations
e: Water Table
TOWN OF NORTH ANDOVER
SYSTEM PUMPING R.ECO:.
I'E'Y1 OWNER & ADDRESS
777 J .
SYSTEM LOCATION
(examPle: left from of no,t)
-)&,Y e--oul-Ppfr`
! E OF PUMPINC:Q (QUANTITY PUMPCD 1066 - -
C,
NO YES SEPTICTANK: NO YES _
-NUKE OF SERVICE: ROUTINE _ EMERCENCY
M>( RV \TIONS:
GOOD CONDITION (FULL TO COVE: t
HFAVY CREASE BAFFLES IN PLACI,
ROOTS LEACHFIELD RUNBACK..
CXCESSIVE SOLIDS FLOODED r,
SOLIDS CARRYOVER Oj�HFR (EXPLAIN.)
M PUMPED BY:
� u,lti-IrNTs:
U'� I I.N 1'� TIzANSFCIZIiED TO:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
{X �l1.4,
DATE:. r
IchK�ICf''
,
' SYSTEM OWNER & ADDRESS
SYSTEM LOCATION
,OON0'ENTS TRANSFERRED TO:
(example: left front of house)
a
777 ah ova
, •+Ulf
7 r
DATE OF PUMPING: " 3 -
a
QUANTITY PUMPED
, GALLONS
- .ulAy
CESSPOOL: NO YES
_._
SEP TIC TANK: NO. YES
�� f NATURE .OF SERVICES
ROUTINE
EMERGENCY
OBSERVATIONS:
r
' GOOD CONDITION •
HEAVY GREASE "--
FULL TO COVER
ROOTS --
BAFFLES IN PLACE
EXCESSIVE SOLIDS
LEACHFIELD RUNBACK
SOLIDS CARRYOVER
FLOODED
OTHER (EXPLAIN) --"'
,. SYSTEM PUMPED BY:
'4
1i
.,COMMENTS:
{X �l1.4,
IchK�ICf''
,
`w
,OON0'ENTS TRANSFERRED TO:
�� O %�J ! //
- .ulAy
4 2001
H/O NAME:
CONTRACTOR NAME:
Type
of Permit or License: (Check box)
RT"
❑
Animal
s`+�;•'�
❑
Town of North Andover
SS�CHus°�
HEALTH DEPARTMENT
CHECK #: ! DATE: D
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 Systems:
❑ Septic - Soil Testing $
❑ Septic - Design Approval $
❑ Septic Disposal Works Construction (DWC) $
❑ Septic Disposal Works Installers (DWI) $
❑
T_it 5 Inspector $
L❑ Title 5 Report $-
❑ Other: (Indicate) $
r
x'592
Health Agent Initials
White - Applicant Yellow - Health Pink - Treasurer