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HomeMy WebLinkAboutMiscellaneous - 79 MARIAN DRIVE 4/30/2018 (2)N VCY,h11 p/CYldrd I h I lomi I?,, 19 ",. n � r oe Ivb/I11110d,jp V11 IOC 11 BCrlrc c''r o'' �� e0erol r 1 OJIIn Or Cinor r A. Faclllty In(o(M�Uon Sys;YOM on: . •. � ','.1 11: lar ; ^ • •'ill GG? ��C.� L�riC•�.� y� �''IIY'P(1;'ly,�,,✓"�.'it'1'��I ,yl ,', y'''•�': 1 II • '� '1,'.Vj%'�ly�l � tl;• n s� '. ,r,.,Jri:�,•, r . f, rr7�I •r�JY1 �mOWn9r,'",•I �� . L/ �-v,�t l'� .IG/11 �i,;,11���. r;�'/i1 �1�.1 I,I`p; Il. rt���;'� i�''. C� -.. • . .�.''�T�t.•'1��'+..'.'��''Y•,1,41'tl.'�N6�11,'''���to�►��'Ir.,. e\`_%9/ t,', 'Iv1QlNI '';� Q uinl rpm buVon) 34 61;Pumpinq,�, agord' • ' I, o umpinp'�' 0►,1 01.1 ,Orhor (des.cr�eej.' m�le�1),1e1 Fll4(,prpo,�onr7 r' Yoe Q n'o .f'j„�',�� its'h�tpl�Jl?,Oji,�'.�;��'i�r4!���i'���'ilTi!�'•'''i :'ti'•',i ly $l 1'11'h4lV1v C�a' , ,,:o.lut,�.�,gl't,'.•'ulrlll�„yll'j,�",'. ,' Syr1 PVr�pe d 6y- 9 y'o�lLA ,vvglbnu �al9 d��posev: ' �' ' �,' ' � .y'� ' ' (� 1" 1, r •.,. S�AIVI 41hIV4(��ii7rf'1, ti „•.main,por/depeier/a9D�oYa�a!Iblorm�,n:�naln $Opus ion, g&7 m.� �rtr Commonwealth of Massachusetts City/Town of No Andover ltt,/I, % 2094 System Pumping Record [HEALTH OWN OFr�ORTHANDOVER Fora t�EPARTMENT s� 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 you local Board of Health to determine the form they use. The System Pumping Record must be submitted tc the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 CMR 15.351. A. Facility informati®n Important: When filling out forms 1. System Location: on the computer, use only the tab 1 __key to move your _ Addres cursor - do not use the return No Andover key. City/Town 2. System Owner Henan Name t5form4.doc- 03/06 Haaress pt ditterent from location) City/Town Ma State State Telephone Number B. Pumping Record _ 1. Date of Pumping �L Date 2. Quantity Pumped. 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: Zip Code Zip Code _0-0V Gallons ❑ Grease Trap If yes, was it cleaned? ❑ Yes ❑ No 6. e14,stern Pumped y: Name Vehicle License Number Stewart's Septic Service Company 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford Ma n1 R�,; Date Date System Pumping Record • Page 1 of 1 RECE V �LN Commonwealth of Massachusetts ,City/Town of, NORTH ANDOVER MASSACHUS TTSJN - 5 2006 System Pum ina Record �+ TOWN OF NORTH AN09VER .�Form 4 HEALTH DEPARTMENT 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. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. ream A. Facility Information 1. System Location: �9 �i7o�r Address ////� City/Town State 2. System Owner: r, ' Name :e Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping t�71qoli Date Type of system: ❑ Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Name Company 7. Location where contents were disposed: Zip Code State de Telephone Number 2. Quantity Pumped: ! ©� Gallons Septic Tank ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number 412 �. Si ature of Hau r Date http://www.mass.gov/dep/water/cl-pprovals/t5forms.htm#inspect t5fonn4.doc• 06/03 System Pumping Record • Page 1 of 1 A/441 yIN1�6VGr 13bAlgosn.Cf, Ni A r9a3^1ro cul c ,6/ •qp �} ! :$:A ;�P- Mo `mu- ADatSS,$ ? 3 LCi ro�)1ct., � ir= 4v` d9 c e.(- r 49rENM4TfS S'MC TAM BEWCE 7 RAIIROAp g BRNM�oW• Mk 01835 978-372-7471 or aoco SM AA 7- 1 d � 7�� 7a �Ll�S/� ✓ % / �S�• 33<P 16TE 7a� Sd �,Kn 7 a 8 tai t tou) Rri J a �® r 49rENM4TfS S'MC TAM BEWCE 7 RAIIROAp g BRNM�oW• Mk 01835 978-372-7471 or aoco SM William F. Weld Gowmor Trudy Coxe Secretary, ECEA David B. Struhs Commissioner Commonwealth of Massachusetts Executive Office of Environmental Affairs Department of Environmental Protection SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION' Property Address: j ' ' a Address- of Owner: Date of Inspection: '• ? .-Fj rr (If different) Name of Inspector: Company Name, Address and Telephone Number: 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: Passes _ Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority Fails Inspector's Sigri ture, Date: �� The Syst m Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing d* 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 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: jqA- One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repsair, 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) 556-1049 a Telephone (617) 292-SS00 i4) Printed on Recycled Paper SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A ` CERTIFICATION (continued) Property Address: Owner: 'wt �P ✓ Date of Inspection: B] SYSTEM CONDITIONALLY PASSES (continued) , / A 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 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: M, 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 nas a septic tank and soil absorption system and is within 100 feet 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 hall 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: dMi ri i efi in 310 CMR 11 have determined that thv olates one or more of the following failure criteria a as defined 5.303. 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. 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. (revised 8/15/95) A u Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) � ,�t�'� two �� � �' �.� f�-�- i� � v �>c• D) SYSTEM FAILS (continued): . 4 _ Static liquid le elm 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 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: The following criteria apply to large systems in addition to the criteria above: The design flow 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 welh I 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. u (revised 8/15/95) 3 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: I Owner: (-d 6 fi�i2, Date of Inspection: F, ,y 7 Check if the following have been done: Xplumping information was requested of the owner, occupant, and Board of Health. _ 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 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. / II 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 Mees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non -intrusive methods. _ The facility o,�ner (and occupants, if differen! from owner) were provided with information on the proper maintenance of Sub - Surface Disposal System. (revised 8/15/95) 4 :4 Property Address: Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION X0--1 g -Pv' FLOW CONDITIONS RESIDENTIAL: Design flow: gallons Number of bedrooms Number of current residents: Garbage grinder (yes or no): ?J " Laundry connected to system yes or no): Seasonal use (yes or no):k/ A WT ` Y Water meter readings, if available: u "V Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow:_gallons/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 E System pumped as part of inspection: (yes or no) If yes, volume pumped gallons Reason for pumping: TYPE OF SYSTEM V 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) ` VV✓1'..e APPROXIMATE AGE of all components, date installed (if known) and source of information: Sewage odors detected when arriving at the site: (yes or no) wo (revised 8/15/95) z SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner: i (; e Date of Inspection: TIGHT OR HOLDING TANK:_ 9 (locate on site plan) r� Depth below grade: Material of construction: _concrete _metal _FRP —other(explain) Dimensions: Capacity: Qallons Design flow: gallons/day Alarm level: Comments: (condition of inlet tee, cond itionl alarm and float switches, etc.) DISTRIBUTION BOX:` � (locate on site plan) Depth of liquid level above outlet invert:° / Comments: (note if level and distribut`,cn i, equa!, evidence of solids carryover, evidence of leakage into or out of box, etc.) 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 A6 • .,. Property Address: { Owner: Date of Inspection: SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) X44 �tj'k PV. P, AW©o (Pekl )Z Ekl6F/Z SOIL ABSORPTION SYSTEM (SAS): Y 5 ' (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, explain: ` p Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number,length: leaching fields, number, dimensions: overflow cesspool, number: Comments: (note condition of soii,`Iigns of hydraulic failure, level of ponding, condition of vegetation,etc.) CESSPOOLS: —14 A - (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.) _ . PRIVY: Y,A (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) Th; SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM -- PART C SYSTEM INFORMATION (continued) Property Address: i P” a, • IMP # v -,e Owner: / t� C Date of Inspection: ( G �lc. - - - SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' DEPTH TO GROUNDWATER Depth to groundwater: .S feet method of determination or approximation: (revised 8/15/95) 9 S' ox Commonwealth of Massachusetts City/Town of No.Andover } System Pumping Record Form 4 1M Ssy`' Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. renmi 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 within 14 days from the pump.iQg date in accordance with 310 CMR 15.351. REF A. Facility Information 1. Syste,�Loc� MAddress No.Andover City/Town Ma State NOV 1 u dpii TOWN OF NORTH ANDOVER HEALTH DEPARTMENT 01845 Zip Code 2. System Owner:�` 1 tL l Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record /0 1. Date of Pumping Date 2• Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Yseptic Tank ❑ Tight Tank ❑ Grease Trap ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: e&—rfj 6. m Pumped ��— Name Stewart's Septic Service Company Vehicle License Number 7. Location where contents were disposed: Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835 Signature of Hauler Signature of Receiving Facil Date/ „ 7y u — f I Date U /j t5form4.doc• 03/06 System Pumping Record • Page 1 of 1