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HomeMy WebLinkAboutMiscellaneous - 784 WINTER STREET 4/30/2018 (2)N r Commonwealth of Massachusetts RECE=IVED City/Town of . System Pumping. Record �� $ 2015 Form 4 TOWN OF NORTH ANDOVER yV� hLj LTH DEPARTMENT DEP has provided this form for us&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 I ht front of Nous ,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 L Cdy/Town 2. System Owner. Name Zip Code Address (d different from location) Ci frown ty State^0p Code ; Telephone Number ; a � j B. Pumping 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) 4. Effluent Tee Filter present? ❑ Yes Leo 5. Condition of System:- . k jv�--/a 6.- System Pumped By - r — Z. Quantity Pumped eptic Tank f. Gallons Y ❑ Tight Tank 0 If yes, was it cleaned? ❑ Yes ❑ No, Neil. Batesbn F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Locaie .% re contents were disposed: Waste Water Date t5form4.doc� 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts ..W.. a *City/Town of F*'O�CEIVED System Pumping Record Form 4 NOV 3 p <<p» k,M S •y`W TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Other forrr����ie—� 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: Le �ightfront Left / Right rear of house, Left / right side of house, Left / Right side of building, ilding, Left / Rightrear of building, Under deck Address City/Town 2. System Owner: Name Address (if different from location) City/Town State Zip Code State bg �Zip Code �v 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 No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterarises Inc Company 7. Location w ere contents were disposed: . _ Lowell Waste Water F5821 Vehicle License Number c(— (,-? -(( - - Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 �LN Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 eye` Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ rdun SEP 5 2 T0WjNi �� i �' .ice � 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. Syst US� Vis`-( Uj) N City/Town State / Zip Code 2. System Owner: 1::�W ov\� Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State .4pvCode Telephone Number 2 Quantity Pumped Date p Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes to - If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � f s 6. Systeip P mped B� �--&,- 1 Name Vehicle License Number I�ZA� Company 7. Location a cpntents ere posed: F SignaYe rauller Date t5form4.doc- 06/03 System Pumping Record - Page 1 of 1 i I tee,,,�,� �4 1 Ute., A,�4 . �x d ,4y t - -k . 7 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORK Address of property PgLf ��h�-�' —St-- ���� � � 0q.olevs owner's name Y'� � � Uj) o � vin \ k u Date of Inspection PART A CHECKLIST Check if the following have been done: Pumping information was requested of the owner, occupant, and Board of H alth. 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 stem recently or as part of this inspection. As built plans have been obtained and examined. Note if they are not ay. ilable with N/A. �Mh- facility or dwelling was inspected for signs of sewage back-up. -sitewas inspected for signs of breakout. �/ All system components, excluding the SAS, have been located on the s e. . y/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 sudge, depth of scum. . The size and location of the SAS on the site has been determined based ��on existing information or approximated by non -intrusive methods. �' The facilityowner and occupants, if different from owner were ( P � ) provided with information on the proper maintenance of SSDS. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION FLOW CONDITIONS If residential number of bedrooms number of current residents garbage grinder, yes or no laundry connected to system, yes or no V seasonal use, yes or no If nonresidential, calculated flow: Water meter readings, if available: MCI Last date of occupancy GENERAL INFORMATION Pumping records and source of information: a -Vj 177y -- \I System pumped as part of insppe'o yes or no if yes, volume pumped Oct O Reason for pumping:.����� Type 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) Approximate age of all components. Date installed, if known. Source of/ information: c� � ` ©:`moi • �'��. fl - � � S� eC AlU Sewage odors detected when arriving at the site, yes or no 9 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SEPTIC TANK: " (locate on site plan) " depth below grade: la/ material of construction: � Concrete metal FRP other(explain) dimensions: �'C'-l'a 1C 1 x I � S- — (Doo 9'wuc3� 'E; tj sludge depth -Tq-'j distance from top of sludge to bottom of outlet tee or baffle S " scum thickness distance from top of scum to top of outlet tee or baffle a' distance from bottom of scum to bottom of outlet tee or baffle 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 leakkage, recomme da,tinJs for epai s, etc. (�l...� _nv 1� e� n4a u.��v� l -1 fi7a&�� © h a . QV 12 DISTRIBUTION BOX: (locate on site plan) depth of liquid level above outlet invert Comments: (note if level and distribution is equal, evidence of solids carryover, eviden a of leakage i to r qut f tox, recomme d tion for repairs, tc.) e t. e ..cry f1% i n-Tz!:) yr (5-4 45 -t - PUMP CHAMBER: t -)o — dcouv I t S�S� . (locate on site plan) pumps in working order, yes or no Comments: (note condition of pump chamber, condition of pumps and appurtenances, recommendations for maintenance or repairs,etc.) SUBSURFACE SEWAGE DISPOSAL 'SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: Type leaching pits and number leaching chambers and number leaching galleries and number leaching trenches, number, length leaching fields, number, dimensions overflow cesspool, number 10 Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition pf vegetti n, recommends io s far maintena a or re g re,e ) r�✓� �fl0vVL �c� G S% c,'kS /l� CESSPOOLS (locate on site plan):'()One, 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, recommendations for maintenance or repairs,etc.) PRIVY: `c�Qv\e„ (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, recommendations for maintenance or repairs,etc.) 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM INFORMATION continued SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' 6(f) -4- 6- -\C) 4- 6- -\0 5 I = 19 1 LO`( O r6 u �.Sa 2: D larr 53 -D3 o r, } v 0- all, Z U [ ,A -o Sa 2 (5'6ct 2D r7 C� r Lie! G EPTH TO GROUNDWATER L' depth to groundwater 'J,- (,pw TZ •�- bot6ok15 method of determination or approximation: 4;vu e4 eJevct�WrN 12 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C FAILURE CRITERIA Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not) t\lBackup of sewage into facility? NDischarge or ponding of effluent to the surface of the ground or surface waters? Nstatic liquid level in the distribution box above outlet invert? NLiquid depth in cesspool <6" below invert or avail'a'ble volume< 1/2 day flow? +/ Required pumping'4 times or more in the last year? number of times pumped t Septic tank is metal? cracked? structurally unsound? substantial infiltration? substantial exfiltration? tank failure imminent? NIs any portion of the SAS, cesspool or privy: below the high groundwater elevation? IV within 50 feet of a surface water? ,V within 100 feet of a surface water supply or tributary to a surface water supply? /V. within a Zone I of a public well? /V within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies only, not.the SAS)? k Awithin 50 feet of a private water supply well? .Al 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 analysi for coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen. 13 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART D CERTIFICATION Name of Inspector Company Name �a�esor t �4 1,1� 1 (�c Company Address l CJ 0vQ,j1�-- I "� . (D l I v certification Staent I certify that I have personally inspected the sewage disposal system at this address and that the information reported is true, accurate and complete as of the time of inspection. The inspection was performed and any recommendations regarding upgrade, maintenance and repair are consistent with my training and experience in the proper function and manitenance of on-site sewage disposal systems. Che one: I have not found any information which indicates that the system fails to adequately protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not evaluated are as stated in the FAILURE CRITERIA section of this form. I have determined that the system fails to protect public health and the environment as defined in 310 CMR 15.303. The basis for this determination is pro din t e FAILURE CRITERIA section of this form. Inspector's Signature Date Original to system owner Copies to: Buyer (if applicable) Approving authority PARKER-DANNER CO. 157 Bedford Street Burlington, MA 01803 617-272-3040 Fax 617-270-0295 r m m D (n D I m Z y"' o Dcn '� ? cz 00 x L ou D z 6\ O 2 7 m D STI 11 I�b C`c 1I zZ01tn c �m M c O �o n m WINTER STREET D z b I to x L t ul N 11 I�b C`c 1I V O I� ,L I pec; o — v D z TO: FROM: NORTH ANDOVER, MASS `�' T 77 19 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 7` )/L///A/ TN iC S "7` North Andover, Mass. SITE LOCATION The grades and construction are as specified in my plans and specifications dated 19 'IUAM ANDOVER BOARD OF h-.ALTH INSTALLATION CIUK LIST DISAPPROVED EXCAVATION OK Date: 11--c 1 I� r`7> --- Reason:* As Built S�zbmitted /� ' • Check: Lot location, dimensions of system, location in regard to percolation tests, depth of system, tirater table 2. Distance to Wetland Areas, Drains, Street & House, Drainage Easement and Wells. 3. Riter Line Location 4.PVC Pipe `- 5. Septic Tank - Tees l . +y Z -'Joints on both side of Tank. 6. Distribution Box - No cracks in 05c or cover 7. Leach Fields - Dimensior lines flow e(, - box. ,Vappec�, lean double -trashed stone 8. Leach Pits- Dimensions, Depth of Stone, Splash pad tees, Cement -pipe to tank - joints on both sides of tank, Clean double -gashed stone 9. No Ga ge Disposals *r 10. '* ading *;barricading of sub -surface system) U i 7- 6' CST' CO&Q,10 Z o 7-5- E :INf-, l� u k, SOIL PROFILE & PERCOLATION TEST DATA Town/City No.&Street a ,iv /t' / Lot No. Loc./Subdiv. ':224-4 ��,.-A///_ plan Owner_ Investigator Observer SOIL PROFILES -DATE /�,.Z�?� 3' Elev. 3' Elev.4'Elev. 0 --'-tet 0 _ ----* 0 ...-..._.__ 0.-- 2 ._ 2 3 v 4 4 � S 6 7 8 9 2 3 4 M M 7 r� 9 1 2, 3 4 kv 61 7 M 9 10 �-____ —� 10 �--�� 10 i 10 Benchmark Location Elevation Datum Percolation Tests -Date Z z2n; Fait Number 1 2 3 4 5 Start Saturation 11,47 3:26 Soak -Mins ° Start Test -Time Dro p of 3" -Time Drop of 6" -Time Mins.lst 3"Dro ,o,,., Mins . 2nd 3"Dro •� ane Lciies on bacK r•rank C. Gelinas & Associates, North And. ^n�� � r`• .' w 1i ..int a,+""`. ." ...,..., ,-. �f �: a 73 - •.+-s�", el- 7. ., re-.. .. •..rr.. .aa. .h+.. w pw - w. ... .r i + 4y+ t / S i0- O00, or' 90 01-7 ._ tib\ Y -" . ► � ; I .. •"_ i � . � -- -- - � v�� -- ( i `wf i yJ .iXO Q(./N OD 0(/_ tA oat . 10..E 00 12'- /if �M / .,/ " `//i�..�_. �%� •I �� W (. 0. co/iJ ',/ypL - • t MVV t ' r � ■ e f � ■ Z �m Z .N LL rn � F-IURD op H&OL-n-t lvoj�-Th & povE),� , w,L4. L�o-r -5 (,Jl k)feK A'?PLI CAN F (,�QTEr{ s�PF'L7 - wt -j D wE� AP oyCDi1�T� SS - SEPTI C SY S T EA l VES16A �ovlJlTio�vs UI �QPPR� VEp Rt 4soms = pwt' AJPR�OVIIJ6 /3uTF1oI'?I-Ty D4� (/ st �'(C SYSTEM l J SIA l(,QTIOAJ eX4VAT(o1,J )ti<<�EGTiO� U/JrG FINAL 6j5p6—�-TloA) A J& T,40r— D S p F,41L APPRoVEP �J/JTC-15 A(o .6P�i47vrn�G A�i+tor�►ry 3 P) T5 IjDrD -`P j�jj CIiV 4PP(TIDMALL I JY Iou5 alt A,3y) DISAPMovED DArC R�So NS •, FwAI APPR)vaL D,oTE. APPi3Ovv-t 6u-)moRlr\ GURU OF' HFA. T�-j. NORTH AAJ DOVE) MA, 7R q IAA,Jr6-1� 'ST ,A ?FU CAN I _ DoK)NI GAk.) (�JgTG--� Sc�i'r�7 �] TbWnl Q WE(.C_ AP�ouCDD4T'L-� 5 S - SC�T'1 c Sy s I EA A I) -si <:A 4 PF ov CD Coy )PITIO vs : D 1 5Q PPRn-VED Ria tos PA -r6', W,e Apf�zOuiN6 /urhoi? ry 5 D� SrPIJ(C SYSTENt 1.� S 1A ll�QT���U YG/jU/JT(o1J 1/vcF'�G►1D�U UArG Q 1i15s E] FAIL_, FINAL WSPEcTloo 4PPROOE'D Uuc-- 7 -!t4 -Z APi'P-D\)INS AuT-HO/RT/ ,4'9P(TjDMAL- Jt-j5F6c, joNS �)j:� koy) DISAPP)�O\j6P PA rC FwAL APPI�pvAL-- DA�� - Zq -K APP►3o,1L&)G 6u -j WINTER STREET lam. ill tv V z- D . it f ' r l F J l {7 f zo /NV2J OD. I IN v� /4�9• 6 NY.= y a r /ptyiG��b•P�. C1C� ?npQ' 0 Inn N. N s�Q l ry. s' r /ptyiG��b•P�. C1C� ?npQ' 0 Inn N. N l co It lbs. S. s• 0e Zo' ■ . r . ti 'w«ice 0 `1 `•t Q � d CIArh m� ZCb 7 - -JCC' Q Qi�A�Q 4N a rN r -m tt� GA t 44A b, zZZZ 3 m FORM 4 - SYSTEM PL1fPM RECORD Commonwealth of Massachusetts , Massachusetts �ystem Pumping Record er Date of Pumping: J J Quantity Pumped: `0!�4allons Cesspool: No �a— Yes : ❑ Septic Tank: No ❑ Yes System Pumped by - Contents transferred to: Date 6 1 l /am- , sz-, _ License #: c� ° Inspector System Otvner Commonwealth of Massachusetts Massachusetts System Pumping Record System Location Sd- Vate of Pumping: ( o a'3 , C �,' Quantity Pumped: lOC4—/ gallons Cesspool: No 1.0Y Yes 11 Septic Tank: No IJ Yes System Pumped by: FdrWoO 5I.aVmaa License # Contents transferrred to : Greater Lawrence Sanitary District - I)pte: Inspector: DATE:" LD1 TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD & ADD -Fa l love 161 0i 1,4%r- S1-- SYSTEM LOCATION (example: left front of house) �rC,VA a� ko Lk Sc DATE OF PUMPING: c QUANTITY PUMPED CESSPOOL: NOYES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: GALLONS YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO:�_ Z • .< - / ) •. TOWN OF SYSTEM DATE: Lv 4 G RECORD CEIVED SEP - 3 2004 TOWN wog- 4ORTH ANDOVER HEALT:�s 'L`=AQ'- MENT SYSTEM OWNER & ADDRESS SYSTEM LOCATION _ 110 (example: left front of house) V\ �^ t,jI f JLr DATE OF PUMPING: -6q QUANTITY PUMPED: 00b GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED To: G.L.S.D d Lowell Waste