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HomeMy WebLinkAboutMiscellaneous - 8 EVERGREEN DRIVE 4/30/2018N O m o m �4 m G o � ^ m bz m o o o � o < o M f t MAP # LOT # PARCEL # STREET �V�F�2�oG�.__.._...._....___.... . CONSTRUCTLON_APPROVAL HAS PLAN -REVIEW FEE 13EEN PAID? ES NO PLAN APPROVAL: DATE c��8/ APP. BY. DESIGNER: Aleve A656G . PLAN DATE._ CONDITIONS ,,9PD/J'i0/V�L '7fei'G 7CCGdc4> 028/ WATER SUPPLY: TOWN WELL WELL PERMIT DRILLER.__._ ._._.__..._....__._...._._... .......... _...__._._.._......._.............. WELL �TEaTS:CHEMICAL DA 1 E Af `PRUVED._____..___.._._._..___ BACTERIA I UA I E fil"PRUVED BACTE II DATE APPROVED.-­­­­­ COMMENTS: PPROVED_­___.___..__COMMENTS FORM U APPROVAL: APPROVAL TU ISSUE YE5 NO DATE ISSUED _BY CONDITIONS: FINAL APPROVAL: ALL PERMITS PAID YES NO WELL CONSTRUCTION APPROVAL YES_ NO SEPTIC SYSTEM CONSTRUCTION APPROVAL YES NO OTHER YES NO ANY VARIANCE NEEDED YES FINAL BOARD OF HEALTH APPROVAL: DATE:_...,.._... DY ttiS It t( r 1 e"(` rj dtt t(t r f r r I _ .1;1� 'A rl. I TOWNwrOF NORTH ANDOVER SYSTEM PUMPING RECORD u c(�AID l�� I .. Ys1� r f IN t.�t it-r„d ?C• 1yt }dT"`^"P"'7 �d r r lit j til- i °t, d{ Fb It ! d} Yb qtr ✓ - e x !,,.; .. _ ., t ��(e`�Tl p��f r��+r r"♦r '�1} i''.r�rt ... t r .. TEM OWNER �' ADDRESS SYSTEM LOCATION. JAI (exam le: left fcout of house) Fv -s ) S) t � ����;FUI+{I'4}{ i X ,. �,jlto tw`„c' k t 6.y '-t.�� •' t , Tt� ���, I} Fd �. � IN � f., x.. r ,. ! , 1,rr , Its• ,t, ;�: 6� ,. � _ ... r-•, .. . '�F�<"t %i'1�1►TR•OF PIMPING:QUANTITY PUMPED 4 yy GALLONS POOL:;,xo YEs SEPTIC TANK: NO _ YES SERVICE:. ROUTINE 4 gg E EMERGENCY 1zm I r�t1S R4`VATIONS:. r` u n �{fit �7f�pr .7'�iter rtt(I}.rjn 7 1, .GOOD CONDITION' ;: HEAVY G FULL TO COVER i GREASE BAFFLES IN PLACE > ROOTS EXCESSIVE SOLIDS LEACHFIELD RUNBACK FLOODED SOLIDS CARRYOVER OTHER (EXPLAIN) .fill, Atj r� r�dl''�; ` 'I. 6r.:' ( :'t I d l• S �_I�It7rcul �.s.j r,�7%et a° r .w �c ' Ap n e ,7'i �! A. 7t�k� iv r r v4 ,{N '� � * --� .rw , ., ,1� IrkiidE W , d7 ` , f" {'! �l °'1 a a•..�;?�•I�r h..r r !, ,; , e. x i } ��t�d, OAVI �C�..�.�-'„-""".,*, .. .:/ '0"'�"^'T' • i s r a I '� �� .3 t � ; rt}.r{x 4 �.,'-F 1y r � . 'I•i � ' ' " .. - �� 'M �,1 �A� 41', ,rT yy � f s� li ! �t � � !' a'., � f � .. _ ..:,+✓'� ,- "fir!NT$r TRAM' ISFE D Tp• • L lug ���?,�t,���C��A ,,v*4 r� � �� L � :j'+ �.Pr`+ Ny• z r !lt:t S 9�Y�u t v I•; .: r ;'ret t t — '9--1 Commonwealth of Massachusetts City/Town of No Andover °. System Pumping Record c Form 4 RECEIVE® JUN 10 2094 TOWN OF NORTH ANDOVER HEALTH DE-PARTM9.Nr 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 Information Important: When filling out forms 1. System Location: on the computer, use only the tab ev, e-'ep key to move your Address cmor-do not No Andover use the return Ma key. City/Town State Zip Code 2. System Owner: H►sh ► n pt,s�L� Name recon Haaress �[T oirrerent trom location) , City/Town State Telephone Number Zip Code H. Pumping Record in /v P 9 Date 1. Date of Pum 2- Quantity Pumped: — Gallons 3. Type of system: ❑ Cesspool(s) AfT Septic Tank ❑ Tight Tank n Grease Tran ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ❑ No 5. Condition of System: 6. tSslem - Pumpe By: Name Stewart's Septic Service If yes, was it cleaned? ❑ Yes ❑ No Company 7. Location where contents were disposed: �iewa s -treatment Plant, 20 So. Mill Bradfol 'Tnature of Receiving Facility Vehicle License Number Ma 01835 Date Date t5form4.doc- 03/06 System Pumping Record • Page 1 of 1 L PIQYIdO(V Jhl# /o/t.q 1,), (100 IQ 00 fQw BQW: a, Faclllty Tln To-'Ir7-'t -� (ion Qn: tN �J'l S �AC H �US E T -T ..�,w,99r r.h�':;y,r,,.•t?q` �!:pr'..ii•+i�, }.NH••", l { - - _ ' 'r,(Y;��11 1j7.�7•�Sy,, rrl}I:!•`\V •!, �� �'.,;sEr ('.,tr.\ ,: .'�+�• 4 �`+• �.1. +•Spy;;'rp"rr\\.i(��•,�•EX,�p�y�J�'' ,,,, •:v".!'lY�a• .. ' ��,r �•' �'•j•;'!!"�i Y'l+ i'��A�, ii1 , � t" • ► r�� '' ® C 0 6 2005 �()WN OF NUK'I'►t ,l�'lh,:�� TOWN OF NORTH ANDOVER J Y 9 TE N •I P lJ M P I N u PAR HEALTH DE' RT c.,r. , ..QOANT1TY PUMPEL` �'t��POOL; N , Yds,• ... NA ►'VKEt t;nle.nur.ti� , 000Ia c0�flrrlu» �/ Yr �YY OY\�,sg ... , VLL r'v waA`MBa IN LFwv�x g+�C�.98rY6.3pl,lpe .rr.., �co� d 4 KVNe����. • SOLD c�lV�YpY��,r.... pmeR -EXPLAIN Cl 44 A.11 l'VMM�NT�, .� � • y TOWN OF NORTH ANDOVER F rioRTM Office of COMMUNITY DEVELOPMENT AND SERVICES O?O`"ztiw eM0 HEALTH DEPARTMENT p 27 CHARLES STREET,..> NORTH ANDOVER, MASSACHUSETTS 01.845 S"H NCHUSES 978.688.9540 — Phone Susan Sawyer, REHS/RS 978.688.9.542 — FAX Public Health Director healthdept@townofnorthandover.com www.townofnorthandover.coni T « From: Fax: Pages: y "_/c Phone: Date: CC: ❑ Urgent ❑ For Review ❑ Please Comment ❑ Please Reply ❑ Please Recycle Please contact the Health Department at the above numbers for further assistance. A e HP Fax K 1220xi Last Transaction Date Time Twe Oct 26 8:58am Fax Sent Identification 819782844600 Log for NORTH ANDOVER 9786889542 Oct 26 2004 9:47am Duration Pages Result 12:49' 13 OK COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION 0 2 TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 8 Evergreen Drive_ North Andover_ Owner's Name: Amy Chen _ Owner's Address: _8 Evergreen Drive_ —North Andover, MA 01845_ Date of Inspection: 9/6/2003_ Name of Inspector: Neil J. Bateson_ Company Name: Bateson Enterprises Inc._ Mailing Address: _111 Argilla Road_ _Andover, Ma. 01810_ Telephone Number: _( 978 ) 475-4786 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: _X Passes Conditionally Passes Nja dF er Evaluation by the Local Approving Authority Inspector's Signature: Date: _9/6/2003_ 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. Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Evergreen Drive_ _ North Andover— Owner: _Chen Date of Inspection: _9/6/2003_ Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: X_ 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 exist. Any failure criteria not evaluated are indicated below. Comments: 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 tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, 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 high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with approval of Board of Health): broken pipe(s) are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 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 ND explain: Page 3 of 11 OFFICIAL INSPECTION FORM e NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 8 Evergreen Drive_ _ North Andover— Owner: Chen Date of I- nspection: _9/6/2003_ C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board 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 in accordance with 310 CMR 15.303(1)(b) that the system is not functioning in a manner which will protect public health, 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 any) determines that the system is functioning in a manner that protects the public health, 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 supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance _ _ "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 than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis 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) Property Address: _8 Evergreen Drive _ — North Andover_ Owner: _Chen _ Date of Inspection: 9/6/2003 D. System Failure Criteria applicable to all systems: You must indicate "yes" or "no" to each of the following for all inspections: Yes No _No_ Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool —No_ Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool _No_ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool No Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 day flow _No_ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped _No_ Any portion of the SAS, cesspool or privy is below high ground water elevation. _No_ Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. _No_ Any portion of a cesspool or privy is within a Zone 1 of a public well. No— Any portion of a cesspool or privy is within 50 feet of a private water supply well. _No_ 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 than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] _NCL_(Yes/No) The system fails. I have determined that one or more of the above failure criteria exist 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 to the criteria above) yes no 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 H of a public water supply well If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has 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 contact 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: 8 Evergreen Drive_ _ North Andover_ Owner: _Chen Date of Inspection: _9/6/2003_ Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No Yes _ Pumping information was provided by the owner, occupant, or Board of Health No Were any of the system components pumped out in the previous two weeks? No Has the system received normal flows in the previous two week period ? No Have large volumes of water been introduced to the system recently or as part of this inspection ? Yes _ Were as built plans of the system obtained and examined? (If they were not available note as N/A) Yes — Was the facility or dwelling inspected for signs of sewage back up ? _Yes — Was the site inspected for signs of break out ? Yes _ Were all system components, excluding the SAS, located on site ? _Yes_ _ 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 ? _Yes_ _ 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: Yes no _Yes_ _ Existing information. _No Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [3 10 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: 8 Evergreen Drive_ _ North Andover_ Owner: _Chen Date of Inspection: _9/5/2003_ FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _4_ Number of bedrooms (actual): _4 DESIGN flow based on 31.0 CMR 15.203 (for example: 110 gpd x # of bedrooms): _660_ Number of current residents: _0_ Does residence have a garbage grinder (yes or no): _No_ Is laundry on a separate sewage system (yes or no): _ No_ Laundry system inspected (yes or no): _ Seasonal use: (yes or no): No_ Water meter readings: Yes_ Sump pumps (yes or no): _No_ Last date of occupancy: _August 6, 2003 COMMERCIAL/INDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): gpd Basis of design flow (seats/persons/sgft,etc.): 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/use: OTHER (describe): GENERAL INFORMATION Pumping Records Source of information: _ Pumped 2 years ago, owner_ Was system pumped as part of the inspection (yes or no): Yes_ If yes, volume pumped: _1500_gallons -- How was quantity pumped determined? _Measured tank Reason for pumping: _ Inspect tank & tees TYPE OF SYSTEM X_ 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: _10 years old, 11/24/1993, As built plan _ Were sewage odors detected when arriving at the site (yes or no): _No Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _8 Evergreen Drive_ _ North Andover_ Owner: _Chen Date of Inspection: _9/6/2003_ BUILDING SEWER (locate on site plan) X Depth below grade: _24"_ Materials of construction: --cast iron _X_40 PVC _other Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): _4" PVC thru wall to septic tank. 4" PVC in house, no leaks. SEPTIC TANK: X locate on site plan) Depth below grade: _12"_ Material of construction: —X—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: _101z 5' x 4' Sludge depth: _7"_ Distance from top of sludge to bottom of outlet tee or baffle: 20"_ Scum thickness: _12" Distance from top of scum to top of outlet tee or baffle: _8" Distance from bottom of scum to bottom of outlet tee or baffle: _17"_ How were dimensions determined: _Difference in sludge & scum depth to tee length _ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): _Pumped septic tank. Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. _ GREASE TRAP: _(locate on site plan) Depth below grade: _ Material of construction: _concrete _metal _fiberglass _polyethylene _other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _8 Evergreen Drive_ _ North Andover — Owner: _Chen Date of Inspection: _9/6/2003_ TIGHT or HOLDING TANK: (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: _0_ Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): _D -box level & distribution equal. No evidence of leakage._ PUMP CHAMBER: (locate on site plan) Pump in working order (yes or no): Alarms in working order (yes or no): Comments (note condition of pump chamber, condition 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: 8 Evergreen Drive_ —North Andover— Owner: _Chen Date of Inspection: _9/6/2003_ SOIL ABSORPTION SYSTEM (SAS): _X (locate on site plan, excavation not required) If SAS not located explain why: Type _X_ leaching pits, number: 3_ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: leaching fields, number, dimensions: 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, etc.): —Soil oL Vegetation oL No sign of ponding to surface. Camera inside of pits thru outlet in d -box. All pits holding no liquid. _ 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 hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: (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.): Page 10 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _8 Evergreen Drive _ —North Andover— Owner: _Chen Date of Inspection: _9/6/2003_ 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. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: _8 Evergreen Drive _ _ North Andover— Owner: _Chen Date of Inspection: 9/6/2003_ SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 4 Feet Please indicate (check) all methods used to determine the high ground water elevation: X Obtained from system design plans on record - If checked, date of design plan reviewed: _4/3/1993_ 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: As per test pit data on design plan._ Sep 09 03 0:3147p N N r r T T r r N r r N N c� u vl 1 i ............... iiiiifS?iJ Z W .7 }cj tYf- t�NrMrMOONr,r% N�I`�000 O • W = Q M LA -O r• 0 0. r N M %0 N W 0. r N Xt O `':`'F`^' ` ii i! ii;i!i C;` O =:� W �? .7 .T 4 Llt Ln Ulf UN Ln L!1 UN %0 b bO I - co u: W Cr N ciLU La ri+ © O.f`NrMrMG7Nrr•©�N�tib Lr 1:�' M N©MUA.Or•00(2,rNM4Or`C70. 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' ` : c•: '� J r � T" T r f T t T T T� T T r T T r O of 5!, IR M�rNMr S ' N ci a2o�s: m I W I I i I I I 1 I I I I I I I I I I V CL E:: -I s 1 J ©©a©rrTTrNNNNMMMM 'lity , -.�;��a=I u.11} vvavvvvvvW V L F- 1 Cj N N N N N N N N N N N N N N N N N �--: U .? 0 O I O Q a Ul 3 1 tt 1" N M 4 U,t c N O O• 0" N 0 Lh .0 N W :::........... t:. a�E E aa�i {• 0�,s cu -C:. n III._ 3 d iL 0 LLJ i Z al y0y N J e P-4 FA Tel: (978) 475-4786 Fax: (978) 475-5451 BATE S ON ENTERPRISES, INC. Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service 111 Argilla Road Andover, Mass. 01810 Title 5 Inspection Report Property Address: 8 Evergreen Drive, North Andover Owner: Chen Date of Inspection: 9/6/2003 My report contained herein does not constitute a guarantee of future usage and the functionality of the existing septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further operation of your current septic system. V J. B�. ea son Bateson Enterprises, Inc. Office Use Only I q e - _ 04r` Tiammumur# of Kassar �usEtts Permit No. p� - t=: +9epartment of Public-'afettl Occupancy A Fee Checked Y BOARD OF FIRE PREVENTION REGULATIONS 527 CMR 12:00 3190 (leave blank) f APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK J All work to be performed in accordance with the Massachusetts Electrical Code, 527 CMR 12:00 (PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date (%* or Town of NORTH ANDOVER To the Inspector of ires: The udersigned applies for a permit to perform the electrical work de s cribebelow. Location (Street &Number) +6V6;A '� Owner or Tenant YQt !� Owner's Address�`� Is this permit in conjunction /with . building permit: Yes C� No ❑ (Check Appropriate Box) Purpose of euiidinei7 1[ L611 �(J�G, Utility Authorization No. Existing Service Amos _J -Volts. Overhead U Undgrnd ❑ No. of Meters New Service Amps _J Volts Overhead 1 Undgrnd C No. of Meters Number of Feeders and Ampacity / Location and Nature of Propose E`lPctrical Work GqC h S No. of Lighting Outlets/ (j i No. of Hot Tubs I No. of Transformers Total No. of Lighting Fixtures Swimming Pool Above— In- d I grnd. '- grnd. �! Generators KVA No. of Emergency Lighting No. of Receotacie Outlets I No. of Oil Burners Battery Units No. of Switch Outlets I No. of Gas Burners FIRE ALARMS No. of Zones Total No. of Detection and No. of Air Cona. No. of Ranges I tons Initiating Devices No. of Disposals Heat Total No.of Total Pumps Tons KW No. of Sounding Devices No. of Self Contained No. of Dishwashers 1 SpaceiArea Heating KW Detection/Sounding Devices Municipal No. of Dryers i Heating Devices KW Local Connection Other No. of No. of Low Voltage `.o. _`. ;"dater Heaters KW Signs Bailasts Wirina No Hvdro Massaae Tubs I No. of Motors Total HP OTHER: INSURANCE COVERAGE: Pursuant to the reauirements of Massacnusetts general Laws I have a current Liability Insurance Policy including ComYp.e�d Operations Coverage or its substantial ecuivaient. YES NO - I have suomitted valid proof of same to the Office. YES {C NO _ If you have checked YES, please indicate the type of coverage by checking the appro to box. INSURANCE BOND - OTHER = (Please Speak✓) / (Expiration Dates Estimated Value of E!ectricai Work S GOBI. bj III WorK to Start Inspection Date Pecuested: Roush Final Signed under the P nasties f pe ury: FIRM NAME C a'✓ IY�p �Z9 9 LIC. NO. Licensee Signature LIC. NO. Ir Bus. el. No. //2 Address h �° ° ' A%'a' � e 1W11 Alt. Tel. No. OWNER'S INSURANCE `NAIVER: I am aware t at the Licensee toes not have the insurance coverage or its substantial eauivalent as re- duirea by Massachusetts General Laws. ana that my signature on this permit application waives this requirement. Owner Agent (Please check one) Telephone No. PERMIT FEE 3 (Signature of Owner or Agent) Date ......;.«3.. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ..... ri�-d .......... tZ .................................. has permission to perform ..... ..........................r. ....................... 1-/ wiring in the building of ........I n,.! to ........ ..................................... at .... J ...... ...... ............ North Andover Mass Fee ... Lic. No. ALECTRICAL INSPECTOR WHITE: Applicant CANARY: Building Dept. PINK: Treasurer GOLD: File J�J P o c m} a �o$ m C y R m � N C403 3 cm m C C � a CO CA W m aC� i • K. L yL•„ O o� c Q Amor o yZ ea > • � c o a E-• m �: H m c a m mL 3 H o � nom V2 ea L m WCL.+ ,.. y O.L O c O r.+ m W •� Q 'O 9 cm L) mCO C40) O. m •j O 'O x moo`a H L S a,m oZCi� � z O E � ` U CLM co C42 O y O c W , O cm E ►'•� a Z o m o m c c •o � N 0\ m L w � Z O � O LU Z a O d aQ v v bam 00 a v w z Q otz w ° w a°' V)) w a m a°' w o rA cn cn o c m} a �o$ m C y R m � N C403 3 cm m C C � a CO CA W m aC� i • K. L yL•„ O o� c Q Amor o yZ ea > • � c o a E-• m �: H m c a m mL 3 H o � nom V2 ea L m WCL.+ ,.. y O.L O c O r.+ m W •� Q 'O 9 cm L) mCO C40) O. m •j O 'O x moo`a H L S a,m oZCi� � z O E � ` U CLM co C42 O y O c W , O cm E ►'•� a Z o m o m c c •o � N m L o � Z O � O LU J Q z CD F- LU Z a O CA } CD c otz w C CO2co •� w O �, m m U z > L- �_ �U D L � � O i CL) CD 0 Q L a y C � Q = C Q Q Q v J -p z .Q Qco Z CD z_ V y R C •� _ W CO)CL CD z z � � LU m cn ,Lpaquamao sadzd ",,--7 ZpaXoauo xoq-a M auo-4S C>h • oxa go moggoS 70 'T,Fe Y/s < Lb ge uoz4En9TS gTTnS-SV 'F auiZ E auzZ Z auiZ Pee T auiZ sgzanul gouaal -98Ino xoq-a s 9 HI xoq-a Ino Xuel (2 HI XUVI asnoH suozgenaTS paso oad H6II'3dSHI 'IVNIa pule ZSI'I =am I'IIIIS-SK November 16, 1993 Ms. Sandy Starr Board of Health 120 Main Street North Andover, MA 01845 Re: Lot 1 Evergreen - S & S Builders Dear Sandy: Find attached a revised plan which contains a provision to install "wick holes" below the bottom of the leach chamber system to be installed on the above -referenced lot. These excavations shall be 2 feet wide, 3 feet long, 6 feet deep and will be filled with clean washed filter sand. This provision will enhance the expected life of the system. We have installed similar provisions in both repair systems and new construction and have found this addition to be a proven addition to the leaching facility. I have instructed S & S Builders to schedule their installer to install these provisions and further to continue on the installation of this system tomorrow. We both know time is of the essence. The installer will be contacting you tomorrow morning in hopes to schedule your future inspections. I appreciate the time and courtesy you have extended us. If you should have any questions regarding this matter please do not hesitate to contact us. Very truly yours, THOMAS E. NEVE ASSOCIATES, INC. C7ZZ� Thomas E. Neve, PE, PLS President TEN/km Attachment cc: S & S Builders • ENGINEERS • 447 Old Boston Road (508) 887-8586 • LAND SURVEYORS • U.S. Route #1 EVERGRN.WPS • LAND USE PLANNERS • Topsfield, MA 01983 FAX (508) 887-3480 gORTol Ott+�ao 6. .-a OL i0- p �,SSAC MUS <� Applicant Town of North Andover, Massachusetts Form No. 3 BOARD OF HEALTH // `f 19 DISPOSAL WORKS CONSTRUCTION PERMIT Site Location UnT -t* Permission is hereby granted to Construct (-I-} or Repair ( ) an Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. 1 Fee ,, J - A 7 lL,-), , CHA MA , BOARD OF HEALTH D.W.C. No, LJ b Town of North Andover, Massachusetts BOARD OF HEALTH DESIGN APPROVAL FOR SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM Form No. 2 a I' Applicant ��' �U/LDE.e� Test o. --C, Site Location .4:�17- Reference Plans and Specs Permission is granted for an individual soil absorption sewage disposal system to be installed in accordance with regulations of Board of Health. CHAIRMAN, BOARD OF HEALTH 'r Fee ,.Site System Permit NO. CO� ; OF O 'rOWOFNORTH ANDOVER L)A 11, SV M _ S M PUMPINQ UCO RI) I .. SYSTEM OWNER & ADDRESS 1 J /V omjo vek j fi%a, SYSTEM �-LOC A RECEIVEL NOV - 3 2004 TOWN OF NORTH AND DATE OF pVMK?qo:_, 9,r..._Q1(JANTITY PUMPED: YES NU YES "A rUR I E TI N OF SERVICE: 10 u . .. .. 0138ERVA'rioNs: OOOD CONDITION FULL'Tyj COVER HEAVY OSE ROOTS BAFFLES IN PLACE. LllACF0ELD RUNBACK ... BXCBSSIVE SOLIDS FLOODED' SOLID CAKRYOVER— " ...... .... . OTRER EXPLAIN 0 �Af e---) WMMENTS. CuNrwrs r'KAN3ytAXZD 1,0 / 01. I I , F1 14, 6 FORM U - IAT REUSE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable local or state law, regulations or requirements. ****************Applicant fills out this section***************** APPLICANT: �� A:5 �, Phone 6 -05 -6912 -9 -62,Z - LOCATION: Assessor's Map Number l0 7 Parcel lelao�-- Lot (s) St. Number A_ **********Official Use Only************************ W' : S OF TOWN AGENTS: N O O b "administrator N v Z Date Approved Date Rejected N H N Date Approved a Date Rejected N Z L Date Approved a -r -Health Date Rejected 1JU Date Approved :tor -Health Date Rejected Public Works - sewer/water connection �I°al' - driveway permit' Fire Department Received by Building Inspector Date BOARD OF HEALTH 120 MAIN STREET NORTH ANDOVER, MASS. 01845 Neve Associates, Inc. 447 Old Boston Road Topsfield, MA 01983 Dear Tom: TEL. 682-6483 Ext. 32 August 5, 1993 The recently submitted plans for Lots 1 & 2 Evergreen Drive have been disapproved for the following reasons: Lot 1: 1. Elevation of foundation drain missing. (N.A. 6.02v) 2. Basement floor not a minimum of one (1) foot above groundwater elevation. (N.A. 4.20) 3. Need additional percolation test at deeper elevation for soil change. Lot 2: 1. Elevation of foundation drain missing. (N.A. 6.02v) 2. Bottom of chamber excavation not 4' from seasonal groundwater. If you have any questions please do not hesitate to contact the office. Sincerely, Sandy Starr cc: Fred Saraceno Karen Nelson DATE Sheet of BOARD OF HEALTH TOWN OF NORTH ANDOVER ( SUBSURFACE DISPOSAL DESIGN REVIEW FEE PERMIT # y DATE RECEIVED �/5/'&7 APPLICANT ASSESSOR'S MAP ADDRESS PARCEL # LOT # -- % ENGINEER NAVE �55�C' , STREET �V�iE6'.C'EC-t/ ADDRESS JJ PLAN DATE - %/�3/9� REVISION DATE CONDITIONS OF APPROVAL: APPROVED DISAPPROVED 1, N&eb � �9T .. �.G V.2-le42 %/©T PLAN REVIEW CHECKLIST ADDRESS ENGINEER GENERAL 3 COPIES STAMP �� LOCUS i--' NORTH ARROW L/ SCALE -c--," CONTOURS 1/ PROFILE SECTION_L,:,-- BENCHMARK SOIL & PERC INFO / ELEVATIONS 701 WETS. DISCLAIMER WELLS & WETLANDS WATERSHED? DRIVEWAY L---�/(Elev) WATER LINEy FDN DRAIN L SCH40 L,--- TESTS CURRENT? A`6�5 SEPTIC TANK MIN 1500G. .17 INVERT DROP t-/ GARB. GRINDER(+200% EDF) 25' TO CELLAR MANHOLE TO GRADE ELEV GW D -BOX SIZE # LINES FIRST 2' LEVEL STATEMENT INLET,Wk' - OUTLET ga 6- d O ( 2 " OR .17 FT) TEE REQ' D? 410 LEACHING RESERVE AREA V 4' FROM PRIMARY?Z100' TO WETLANDS 2% SLOPE(/ 100' TO WELLS 35' TO FND & INTRCPTR DRAINS 4' TO S.H.GW 325.' TO SURFACE H2O SUPP-:/ 4' PERM. SOIL BELOW FACILITY MIN 12" COVER c/ FILL? (25' if above natural elev• 10'' below) BREAKOUT MET? TRENCHES MIN 660 gpd SLOPE (min .005 or 6"/1001) >3' COVER? - VENT SIDEWALL DIST. 2X EFF. W OR D (MIN 61) IS RESERVE BETWEEN TRENCHES? IN FILL? MUST BE 10' MIN. 4" PEA STONE? BOT X LDNG + SIDE X LDNG = TOT (L x W x #) (G/ft2) (DxLx2x#) PITS MIN 660 LEACHING EXCAV 2x EFF W OR D baa BOT 4Z/. $ (L * --.W-"x_ # r GW MIN 4' BELOW BOTTOM MANHOLE/PIT 12"=48"_STONE SURROUNDING 1?61 x LOA.D37 = TOTAL ,,/% 7�"/a ( 2 x (L+W) x D x #) CHAMBERS / / MIN 660 LEACHING l/ GW MIN 4" BELOW t/ COVER >3 FT - VENT MANHOLES ti/ 12"-48" STONE '� SPLASH PADS —'� SLOPE .005 BED/TRENCH n/C (Bed max. 60' X 601) c BOT 4P. K3 J �Ci/ + SIDE 19l, l S `3 �/' X LOAD (L x W x #) (2 x (L+W) x D x #) FIELDS = TOTAL 4� MIN 900 ft2 LEACHING PERC RATE FASTER THAN 20M/IN GW MIN 4' BELOW BOTTOM OF FIELD PIPE ENDS JOINED W/NON-PERF. PIPE? 4" PEA STONE? DIST LINE SLOPE .005? >3' COVER - VENT SCH 40 MIN 12" COVER L x W = T x LDNG > DESIGN FLOW? DOSING TANKS AND PUMPS DIMENSIONS X X = PUMP CAPACITY gpm L W D Vol. DISCHARGE SIZE DISCHARGE RATE DISCHARGE TIME gPm MANHOLES TO GRADE ALARM SEP. CIRC. GW (Min. 1' below inlet) HWL LWL CHECK VALVE BLEEDER HOLE MANUAL OP. SWITCH 9,2U NO eELGI-k' 0,2 Bl956-M6Ni FG.Ua2 5,yAz-c- B� 1Es�5 7-1�,9nI 'p ve C/) Goa✓`�i/�X. G, ct) , &Z&v. a Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 1 , 32Oy �SED b`e��pL �.,%iCiIJC.._ I �J 9 o s m Ie 1 J E ,p " APPLICATION FOR SITE TESTING/INSPECTION Applican NAME ADDRESS f � � Site Location) j--�"--�— t tS Engineer's �' { NAME / ADDRESS TELEPHONE Test/Inspection Date and Time CHAIRMAN, BOARD OF HEALTH Fee Test No. G i f S.S. Permit No. D.W.C. No. C.C. Date Plbg. Permit No. TOWN OF N, SYSTEM PUMPING RECORD fiT yfq.'rs DATE ._ 7 SEP - g 2003 I SYSTEM OWNER & ADDRESS SYSTEM LOCATION __ . J 6t��� (example: left front of house) f DATE OF PUMPING: QUANTITY PUMPED: (� GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE 4-�/ 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: ` '"i '� k��� ,C �y."r: � � +r a ���♦1;) 1 t � y alp, t t>, � 4/� � .... ,��s Comronwaith of Massachusetts 3 '°tv/Town ef.NORTH ANDOVER. MASSACHUSETTS cityrrown s. . State9 up cooe Telephone Number B. Pumping Record a;, 1. Date -of Pumping U(p 2. Quantity Pumped: � C Date Gallons Type of system:. ❑ Cesspool(s)pt�ic Tank ❑ Tight Tank Signature of Hauler Date ' http://Ww4.mass.goV/dep/water/approvals/t5forms.htm#inspect ❑ Yes o t5form4.doc• 08103 System Pumping Record • Page 1 of 1 G.,.Ui:;�• : �.:��., qr r�: n �r,,ari}1'pI•G:i :�,r..J�l �". "�3• ' 5:�,'� � '�n , '�• •--' r•' );',•.}i: 4' I .; •a:j�::ar�� rt �'?f'% r `�lr'Or{iaf'�•;•z'..�?"�uli'r. ,r� q�! • ID r �'1�.'y' • 'r { % Ir@C.QI Y_.`CYo `49 a�Y v^r�w• , •'.7'Y - ( r ��7�J�Sr� .}��' 1Ml�'�i J+ y-`''1:U'.:i'l'1' .. :;.�'. , ,i ''•.�'{ro.�. Y�F':'1! 1'�L, 7�,; .1��{���/)a\:(L itl.!r. n.: ..:I:'t,L y •1 r,.•"S,ty ,,(�I�.IJYl,r.^.l.� r•l�,C,k�r,lY"''J.rar:;r; is p yy p •,•(r.:..,� v �,�y,:♦:,•i<� r,�1, � 7.: . ! id;, n.li:'1'.4''' ,t.. R 1 200 t\,:t';I,�.L,{I�••D a 1':v'al Off" MA, V U ' DER rovlded vf'.. p, ls,form for use by local Boa ds of Health, The S�sSe Pumping Record .T be submitted to the.local'Board of Health or othe eP)p 9 �'aut ori "rovin �T �•: y :', :%, ; {;..,,':<. HEHLI ri Jrrp I lei � o A:. Faclllty .lnforritlon i trTtDO(t1fi� J1•y±J1en (1inp out `;1; . System Location;' only the tab key Address to move your . do (lot; `;:,:: ��•rh.'rowm:Y';:;I.:;;,;:,,Clty/1'vwn .;; .:. •,.. ' . Sial • ' :;:,•�y 417�!'w'4'ta,•4;,•:,.,;•,•,.;.ti;;�;,�,.�:1��:,.,',;; :'• `''`;;' •":;' �:�:,,' .. .. e ..,, Z1p Coda .'� '?r,;J• L•fls;�,;:.,;, 1�.,•.S�SteRl Owner,"� .r4.,,,,-; �� r . • .�•, \)L' 11 :y(�+.:•r.r'Yr'ry; 'rt�ct,l ,1: •pa t;J r. ,,,;�; �'•Nilile'•'17 7r' !�•.,r•.!(1.g,.nrr,i.r., "' 1,(it different from be tion) �. , �;; CtyRown. ��1„ •:�;:.`' ,.:,• State' � ( 1 umpind 8 R fiord' i ^�• 1 %tw 'F�{�trr rrrht,rJl�l�'4t1'J`111 .� r1 � a. � ., ,•� ` 1 Date of Pumping Dale 2, Q.U811 y Pumped: r ; CiillOni 31Type of system; ; ❑ Cesspools) Septic Tank r, •; :•�, Cl Tight Tank Telephone Number . .. , •:��� � %Other (descrftia �,�•,';�� � ' ;:.C� ;,' �?•�:�,;�;,''l,:s'ri�jriL;��irl�+y.;;;:;;,:;S,�Yjr'�c�:,.,.• C. psent?.❑ Yes ❑ No' �i,; ,•,,G1• }'' '•" !'rl; ;t '4 r '. +1 I�1orim ,,. .. ..: .I :p•:y.i�t:i %lu• rJ'(1'://,h�1 I,w',1•b� ,! rn l:r• i'', � :!\ _"y�„�'�•l4q�7ii1:)�;•��r,l:,�(,P�;�ii�r•hr��:;i�,•�ir}�r,i:;a,' ..121 .�: I.i �'•' '.),./•r, 1•�r�.. �fl f• ,��tl't.��4t%(•',411•'41'r �i fl�l `'1.. ,:.,r :{•�• P,4Jmpod By;'' If yes, was It cIeaned? ❑ Yes ❑ No t.',1 :��/ .,', .:irS1;1^.• iii l!1,/�j1 tY �//J�/�/�J�]� ,r•''l' , f';• v;> {� /r;.l�+lYl: r. �j•� .�,�, 1 r {� �: t Vl(�{ � r r Ivt't'{ •'' •)'''(; - �- , - ... . �L.• ',.. :i y/�,i' r �•r;,:. L'lU•f11r ,: �t }i (/��,yl I,,t. r,ji1}i t.• . �t•.��>,t./t,r,,•�:•�lv.r►'}riaWiyj.J�..�iNtll:�',lii�t•.i•,.v�'r; ... 1; i �'�,Fi;i;4i! i 7r r o Where onle e , c nts'yr, re disposed; •� �•;,.. ,'' r, , 1`� ' ` 1 ver , . ^S`rt/,. 'i t }ti �l�ll • , .. � J n r r�. J•J r i 14;t`�'r' Jr %Y ,^Irti'i t r',ti 1 ' r t V('4i�i' 4;; -. _ - .'-. ..� s'' 1 t • :1• ' _.' Y: u�:. rt 4."i1�%1,.', t....l., �%��ir� ri1;.L, � .... • httpJlwi w,maas• ov/da,.... , .� 9 F!wafa�/a pp rCvaJs%t6forms htm#Inspect t5tarrM,doa; 081Q3 ',; � • ' System Pumping Record ' P;ge t — ,,,.F,� ,; �.; . . ' 4 l �..A ..... ^+ � -' _... i. t -. �.. 4•��1j1 •� s} ;;.+.. •, �I+�ti ;'lel .•i., .. ryr'�fwi14 DEP has provided this form for use by loyal Boards of Health. The System Pumping Record mu, be submitted to the local Board of Health or other approving authority. V A.. Facility Information Important: When filling out 1. forms on the computer, use only the tab key to move your cursor •, do not use the return key,.... 2, http:/Avww.rhass.gov/d.epA,—v6ter/aoprovals/t5forms: htm#inspect "ql 1 vwn State Zip Code Address (If different from location) Cityrrown State Zip Code telephone Number B. Pumping Record 1. Date of Pumpinggate 2. Quantity Pumped 3'... Type of system:. ❑ Cesspool(s) 'Septic Tank y {] Other (describe): ' Ga ons ❑ Tight Tank 4, Effluent Tee Filter present? ❑ Yes ❑ No If yes;'nvas it cleaned? 0 Yes ❑ No 5. Condition of System: Lemp d BnM om( Y fV}e/hiide License Number Company, 7, Locatio�where contents were disposed: t5fom►4.doa 08/03 System Pumping Record - Page 1 of 1 1t Commonwealth of Massachusetts W City/Town of North Andover ° System Pumping Record Form 4 M 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 � tem x accordance with 310 CMR 15.351. �I>��( EIVEw i'__�Clnaturel Tiauler Date Signat of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1 A. Facility Information T 18 �'Js 1 Important: When filling out 1. System Location: F NORTH ANDOVER LHEALTHDEPARTMENT �Tr"viE►�'T forms on the / rn /� e computer, use V only the tab key Address to move your No.Andover Ma 01845 cursor - do not use the return City/Town State Zip Code key. Q 2. System OwneK Name Address (if different from location) City/Town State Zip Code Telephone Number B. Pumping Record % ' 1. Date of Pumping Date 2. Quantity Pumped: Ga o s Gallons 3. Type of system: ❑ Cesspool(s) EL,5sptic 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: C 6. stem Pumped By: (! L�-O4 IVehicle Name License Number Stewart's Septic Service Company 7. Location where contents were disposed: Atewart's Pre-treatment Plant, 20 So. Mill Bradford. Ma 01835 i'__�Clnaturel Tiauler Date Signat of Receiving Facility Date t5form4.doc• 03/06 System Pumping Record • Page 1 of 1