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Home My WebLink AboutMiscellaneous - 804 FOREST STREET 4/30/2018O 0. O Lrllqih. Commonwealth of Massachusetts City/Town of SEP 2 3 2013 System Pumping Record Form 4 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. System Location: Left/ Right front of houseof Righ rear of hous Left/ right side of house, Left/ Right side of building, Left / Right front of bu mg, Left / Right rear of building, Under deck Address C c City(Town 2. System Owner. Name Address (if different from location) + NoNqv" t State Zip Code Citylrown State jl f '7— t r--� Coc?0 % Telephone Number B. Pumping Record j 1. Date of Pumping 2. Quantity Date �Y Pumped: Gallons 3. Type of system: ❑ Cesspool(s)Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No. 5. Conditioori f/stem:� 6. System Pumped By: Neil Bateson Name Bateson Entemrises Inc Company 7. Location where contents were disposed: S•Q Lowell Waste Water t5fomm4.doc• 06/03 F5821 Vehicle License Number Date System Pumping Recons • Page 1 of 1 a �10R�q 5367 Of 9 ❑ r° s Town of North Andover $ HEALTH DEPARTMENT ,JSACHU'+�� Body Art Establishment CHECK #: DATE: ` �� LOCATION: $ H/O NAME: Dumpster 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 $ ❑ TrashlSolid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ �tiftle5Elinspector $ eport $ P ❑ Other. (Indicate) $ Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer �Jry� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Asses; Property 0 c - +encs TOWN pp NQftfiM ANpGYIER Owner owner's16rhg-/ information is �) P� required for fV �� "" every page. City/Town State Zip Coodede Date o Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. WGI A. General Information 1. Inspector: C c4 r l� Name of Inspector company Name i n Company Address �IG51�U� 0/�7� City/Town State Zip Code Telephone Number License Number B. Certification 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 Title7Passes 10CMR15.000). The system: ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority I s to Si ature Date 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. ""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. (� 151ns - 08/08 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 1 of 17 L� Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Information is Owner's Name required for every page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E / always complete all of Section D A) System Passes: [� 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. UM 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) for the following statyements. If "not determined, " please explain. The septic tank is metal and over 20 years old" or the septic to (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltr on or tank failure is imminent. System will pass inspection if the existing tank is replaced with a mplying septic tank as approved by the Board of Health. A metal septic tank will pass inspection if it is ucturally sound, not leaking and if a Certificate of Compliance indicating that the tank is less thad 20 years old is available. ❑ Y ❑ N ❑ ND (lain below): t51ns - 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 2 of 17 Commonwealth O Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Prope ddress • Owner Owner's Name Information is required for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) B) System Conditionally Passes (cont.); ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ (Explain below): ❑ The System required pumping more than 4 es a year due to broken or obstructed pipe(s). The system will pass inspection if (with appr al of the Board of Health): ❑ broken pipe(s) are replace ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is remove ❑ Y ❑ N ❑ ND (Explain below): 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 deter • es in accordance with 310 CMR 15.303(1)(b) that the system is not functionin a manner which will protect public health, safety and the environment: ❑ Cesspool or privy iswith' 0 feet of a surface water ❑ Cesspool or pri within 50 feet of a bordering vegetated wetland or a salt march t51ns • 09/08 Title 6 Official Inspection Form Subsurface Sewage Disposal System • Page 3 of 17 Owner Information is required for every page. Commonwealth of Massachliasetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town B. Certification (cont.) State Zip Code Date of Inspection 2. System will fail unless the Board of Health (and Public Water Supplier, if any) deterimes 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 eet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is le 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, bacteria indicates absent and the presence of ai less than 5 ppm, provided that no other failure attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: rmed at a DEP certified laboratory, for coliform is nitrogen and nitrate nitrogen is equal to or are triggered. A copy of the analysis must be You must indicate'`Yes" or "No" to each of the following for all inspections: Yes No ❑ L1a 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 ❑ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Ef V � ❑ Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 4 of 17 Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments �6<< Ste, - Property Address Owner's City/Town B. Certification (cont.) State Zip Code Date of Inspection Yes No ElLJ 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. ❑ E� 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 1 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 fecal coliform bacteria indicates absent 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 and chain of custody must be attached to this form.] ❑ This system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ 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. For large systems, you must indicate either "yes" or "no" to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 fe a surface drinkiing water supply ❑ ❑ the system is within feet of a tributary to a surface drinking water supply ❑ ❑ the system is cated in a nitrogen sensitive area (Interim Wellhead Protection Area - IW or mapped Zone II of a public water supply well If you have answered "y C to any question in Section E the system is condidered a significant threat, or answered "yes" inKecion D above the large system has failed. The owner or operator of any large system consider 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. t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments a Property Address Owner Information is Owner's Name required for every page. City/Town State Zip Code Date of Inspection C Checklist Check if the following have been done. You must indicate "yes" or "no" as to each of the following: Yes No LI ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ [g Were any of the system components pumped out in the previous two weeks? L'J ❑ 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? Er/X ❑ Were as built plans of the system obtained and examined? (if they were not available note as N/A) ❑ Was the facility or dwelling inspected for signs of sewage back up? 01 ❑ Was the site inspected for signs of break out? ❑ Were all system components, excluding the SAS, located on site? 2 ❑ 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? d ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? This size and location of the Soil Absorption System (SAS) on the site has been determined based on: ✓❑� ❑ Existing information. For example, a plan at the Board of Health. ❑ Determined in the Feld (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5')] D. System Information Residential Flow Conditions: Number of bedrooms (design): --� Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): d 0 t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 6 of 17 a Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Owner's Name City/Town State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? 3 ❑ Yes No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes R(No Water meter readings, if available last 2 years usage d t Detail: (X) AIV, is �I Sump pump? Last date of occupancy: Commercial/Industrial Flow Conditions: Type of Establishment: Design flow (based on 310 CMR 15.203): Basis of design flow (seats/persons/s ,etc.): Grease trap present? Industrial waste holding Non -sanitary waste discKarged to the Title 5 system? Water meter readings, if available: Gallons per day (gpd) ❑ Yes Z No Date ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t51ns - 09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 7 of 17 i; Owner Information is required for every page. Commonwealth of Massachusetts Title,5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Owner's Name City/Town D. System Information (cont.) Last date of occupancy/use: Other (describe below): Pumping Records: State Zip Code General Information Date Date of Inspection Source of information: Was system pumped as part of the inspection? ❑ Yes No If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type o,f System: lJ 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) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other (describe): t5ins • 09108 Title 5 Official Inspection Forth Subsurface Sewage Disposal System • Page 8 of 17 Owner Information is required for every page. commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) a dsource of information: Were sewage odors detected when arriving at the site? ❑ Yes V No Building Sewer (locate on site plan): Depth below grade: ' feet Material of construction: ❑ cast iron ❑ 40 PVC ❑ other (explain) .,AJ I -A Distance from private water supply well or suction line: AA -A feet Comments (on condition of joints, venting, evidence of leakage, etc.): ''J5ecV"'sI Septic Tank (locate on site plan): Depth below grade: Material of construction: 9 concrete ❑ metal ❑ fiberglass ,z/ 1,� feet ❑ polyethylene ❑ other (explain) If tank is metal, list age: �I years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: � Sludge depth �. 5 t51ns • 09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System •Page 9 of 17 conmmonwea .th of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner Owner's Name Information is required for every page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank (cont.) Distance from top of sludge to bottom of outlet tee or baffle 0 4 Scum thickness i Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle How were dimensions determined? <5 1y d 6Tj e -Jv_d �t Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid Igvels as related to outlet invert, evidence of leakage, etc.): NAM, Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ Dimensions: Scum thickness Distance from top of scum to topi6f outlet tee or baffle feet ❑ polyethylene ❑ other (explain) Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins - 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 10 of 17 � e Owner Information is required for every page. Q mmonwealth of Mas achusetfs Title 5 Official Ins ection Form o rm Subsurface Sewage Disposal System Form - Not for Voluntary Assessments .. Property Owner's Name City/Town State Zip Code D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or liquid levels as related to outlet invert, evidence of leakage, etc,: Date of Inspection condition, structural integrity, 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: Design Flow: Alarm present: Alarm level: Date of last pumping: Comments (condition of alarm gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No / Date float switches, etc.): * Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 09/08 Title 5 official Inspection Form Subsurface Sewage Disposal System • Page 11 of 17 ao Owner Information is required for every page. ttsins • 09/08 Commonwealth of Massachusetts Title 5 Official inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments SSU q�l- Property Address Owner's Name City/Town State Zip Code Date of Inspection D. System Information (cont.) I 1,-5� Distribution Box (if present must be opened) (locate on site plan): o� Depth of liquid level above outlet invert � 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.): -ex)-PA 4IA,3,—M)V)]MA I Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes ❑ No Comments (note condition of pump chamber, conditi/pumpsnd appurtenances, etc.): .Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 12 of 17 C;omm'onwealth of Massachusetts Title 5 Offici al inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0 Property Address Owner Information is Owner's Name required for every page. City/Town (t5ins • 09/08 State Zip Code Date of Inspection D. System Information (cont.) Type: ❑ leaching pits number: ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: leaching fields number, dimensions: 07 0 Y y S� ❑ 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.): Lm --A,. ' No--Da-nA IY1 � A n 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 ❑ No Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 13 of 17 a i; Owner Information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments ell uwner's Name City/Town D. System Information (cont.) State Zip Code Date of Inspection 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 by aulic failure, level of ponding, condition of vegetation, etc.): (t5ins • 09/08 Title 5 Official Inspection Form Subsurface Sewage Disposal System • Page 14 of 17 Owner Information is required for every page. (t5ins • 09/08 CommonWealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 0� Property Address Owner's Name Citylrown U. System Information (cont.) State Zip Code Date of Inspection Sketch Of Sewage Disposal System: Provide a view 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 buildi g. Check one of the boxes below: hand -sketch in the area below S ❑ drawing attached separately V S ao Title 5 official Inspection Form Subsurface Sewage Disposal System • Page 15 of 17 a Owner Information is required for every page. Common -Wealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's City/Town D. system Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water / ❑ Check cellar J ❑ Shallow wells Estimated depth to high ground water: State Zip Code Date of inspection O feet Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record If checked, date of design plan reviewed: Mare— 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: Before filling this Inspection Report, please see Report Completeness Checklist on next page. (t5ins - 09108 Title 5 Official Inspection Form Subsurface Sewage Disposal System - Page 16 of 17 z Owner Information is required for every page. Mns - 09/08 C60impnweaith of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Property Address Owner's Name Cityfrown State Zip Code Date of Inspection E. Report Completeness Checklist Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems) completed System Information - Estimated depth to high groundwater 114 Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file Title 5 official Inspection Form Subsurface Sewage Disposal System • Page 17 of 17 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 M DEP has provided this form for use by local Boards of Health information must be substantially the same as that provided I local Board of Health to determine the form they use. The Sy the local Board of Health or other approving authority. r A. Facility Information RECEIVED AUG 11 2009 forms may be used, bu the ihti9lii�e}t ck with your submitted to 1. System, Location: Left side of house, Right side of house, Left front of house, Right front of house, rear of hos , ght rear of house. Address (`�`1 7 4 C--N--t jA n i <I City/Town 2. System Owner: Name Address (if different from location) City/Town State (f��UOLAe, Zip Code S 6 / Zip Code Tele -phone Number B. Pumping Record 1. Date of Pumping Dat 2. Quantity Pumped: Date Gallons 3. Type of system: ❑ Cesspool(s)R—S'eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes If yes, was it cleaned? ❑ Yes ❑ No 5. Conditio of S AA—", / ) V\, 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: ;L. Lowell Waste Water Vehicle License Number F5821 Date ' t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 M441 Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. VQ nem X Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 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. Syste Locatio <nK-- hoLis-e Address Citylrown �{ 2. System Owner: Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): State Zip Code State Zip Code 7 Telephone Number e-3 3- a-? Date 2. Quantity Pumped; Cesspool(s) Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes D No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition �Systtem: "A 6. System P m By: Name Vehicle License Number vf�" ��V-"— Company 7. Location Signature of t5form4.doc- 06/03 nt nts w Isp s -, sz�� Date System Pumping Record • Page 1 of 1 4- 0 1 v CD CL N _O ^U W ZEE 2 ro in 7A U- 4- ^O W 4-J c 0 C) 42L < 0 F- C V to 0 u 0 G 0 m H O c. L L 9 ZT 0 .1.r ccQ) Q C Q% = .}0 V CGQ a� H c 0 t a (D E U O O C Commonwealth of Massachusetts P- Massachusetts Svstem Pumping Record System Owner ple� Date of Pumping: q— — (' 1 Cesspool: No � Yes U System Location —1 Quairiity Pumped: 10'P—)gallons Septic Tank: No U Yes i�f— System Pumped by: Edt`e4o1rt t �P,d License # Contents transferrred to : Greater Lawrence Sanitary District Date: _ Inspector: .RCS Qty jEAL .4f`ri/ � J Ty = TITLE V INSPECTIONS FILE #NA917 qe n Dean G. Luscomb 11 & Sons P.O.B. 135 Middleton, MA 01949 - r-�`' 1-508-774-4065 . LICENSED PLUMBER #20285 23 r b 8s. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY OWNERS NAME: ►`nl A PROPERTY ADDRESS:p p d 1'D rp S 4- N A n C�D I��e ►'' %�%%� ADDRESS OF OWNER: Q lY) P ( i7 different) ` DATE OF INSPECTION.- �� P 0 p r'n he f j �T_ q NAME OF INSPECTOR: De Q n C Lu S' b rn h Q U A L I T Y I S N U M B E R C N E T C U WILLIAM F WELD Govemor ARGEO PAUL CELLUCCI Lt. Govemor COMMONWEALTH OF MASSACHUSETTS Dean G. Luscomb II & Sons P.O. Box 135 Middleton, MA 01949 1-508-774-4065 EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET. BOSTON, MA 02108 617-292-5500 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: FG7 Fe'r-eN� �n do11el Address of Owner: Date of Inspection: pf-�,,�Cr /-7 y �99� (If different) Name of Inspector: nPan G_ T.nernmb II I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) Company Name: D an , uGcomb TT F. Sona Mailing Address: POB 135. Middleton, MA 01949 Telephone Number: 1-508-774-4065 TRLDY CORE Secretary DAVID B. STRUHS Commissioner 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: y Passes _ Conditionally Passes Needs Further Ev uation By the Local Approving Authority _ Fails Inspector's Signature: Date: 57, 1-7, / Ncf The System Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (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 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: Che A, B, C, or D: A) SYSTElv1PASSES: 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. COMMENTS: BI 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. Indicateyt;s,no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not. k,The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or the septic tank, whether or not metal, is 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 04/25/97) Pay 1 of 10 DEP on the World Wide Web: http:ltwww.magnet.state.ma.us/dep 0 Printed on Recyded Paper Dean G. Luscomb II & Sons t Middleton, MA 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:0/�'/ Foees `�� /J' AI7a//ve.(' Owner: S . iii m/9 A Date of Inspection: 61 SYSTEM CONDITIONALLY PASSES (continued) NSewage 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 tw th approval of the Board of Health). Describe observations: 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 C1 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 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 PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: �i The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or tributary to a surface water supply. N The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well. LV The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well. The system has a septic tank and soil absorption system and the SAS 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. Method used to determine distance (approximation not valid). 3) OTHER L tiv (revised 04/25/97) Page 2 of 10 0 Dean G. Luscomb II & Sons Middleton, MA 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A / n CERTIFICATION (continued) Property Address:96 V Fr�s� St /J- AnWatl{',— /7& Owner: Siy/i ZZC` Date of Inspection: 9/17/7 D) SYSTEM FAILS: You must indicate e;; er "Yes" or "No" as to each of the following: I have determined that the system violates one or more of the following failure criteria as defined in 310 Ct-oR 15.303. The basis for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure. Yes No _) Backup of sewage into facility or system component due to an 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. Static liquid level in 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). I Number of times pumped NAny port on of the Soil Absorption System, cesspool or privy is below the high groundwater elevation. Iv Any port on of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. 1� 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. Iv 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: Youm st nd�cate either "Yes" or "No" as to each of the following: Ilowing criteria apply to large systems in addition to the criteria above: The system serves a ity with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public health and safety an environment because one or more of the following conditions exist r- _--• - ----- Yes No the system is within 400 feet of a surface dri _ the system is within 20 e> of a tributary to a surface drinking water I the s is located in a nitrogen sensitive area (Interim Wellhead Protection Area - ) or a mapped Zone II of a I c water supply well) jk�e owne" r or operator of any such system shall bring the system and facility into full compliance with the groundwater treat >�rogram requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information. (rovis*d 04/25/97) Pag• 3 of 10 Dean G. Luscomb II & Sons Middleton, MA 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address F -d Owner: S/ni TG Date of Inspection: 9l17✓QR Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yes No N�A J Pumping information was provided by the owner, occupant, or 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 ben obtained and examined. Note f t�ey are not available with N/A. ��ofOo3?� ��ac✓iHIs w iG Vcif C/oS4 1�0 4AX - —as 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. All 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 tees, 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: The fac l tv owner (and occupants, if different from owner) were provided with information on the proper maintenance of . Sub -Surface Disposal System. Existing information. Ex. Plan at B.O.H. Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) (15.302(3)(b)j (revised 04/25/97) Page 4 of 10 Dean G. Luscomb II.& Sons Middleton, Ma 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address:,gv/ ores Owner: �/� Date of Inspection: '?/17 /�f( FLOW CONDITIONS RESIDENTIAL: Design flow:,3,30 g.p.d.,rbedroom for S.A.S. Number of bedrooms: Number of current residents: Garbage grinder (yes o no . )0 ,,// Laundry connected to syste yes or no): res Seasonal use (yes or no):A—)o Water meter readings, if available (last two (2) year usage (gpd): Prl l%� ,(io•� � CCS, gyp/ cle onot O IJ� Sump Pump (yes No e /Vo'— luatt,r Last date of occupancy: [J&zr e,, ERCIAUINDUSTRIAL: Type of establ ment: Design flow: g day Grease trap present: (yes or no)_ Industrial Waste Holding Tank present: (yes Non -sanitary- waste discharged to the Title Water meter readings, if available: Last date or occu OTH escnbe) date of occupancy: GENERAL INFORMATION PUMPING RECORDS and source,ofinformation: System pumped Is part of inspection: (yes'OKZno If yes, volume pumped: /4000 gallons Reason for pumping: A -j. kje,,j + +L-j_V ir,,e_ TYPE 06�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) I/A Technology etc. Copy of up to date contract? Other 7 eae- )C,, 1-4 �oQs T'4e�e 44--a T� APPROXIMATE � ofcomponents, date installed (if known) and source of information: 12Z a3Z712Las-e' Sewage odors detected when arriving at the site: (yes orQ. (revised 04/25/97) Page 5 of 10 Dean G. Luscomb II & Sons ,. Middleton, MA 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Pr �o y F r4s �- S�. �, A nd0opeVe rty Address; Or: Srh' �- Date of Inspection:,?// 7167 BUILDING SEWER: 1/�S (Locate on site plant / Depth below grade: Material of construct on: /cast iron _ 40 PVC _ other (explain) Distance from private water supply well or suction line N Diameter ,f Comments: (condition of joints, venting, evidence of leakage, etc.) Zev, ! / n r'4a , 7 , r / ; Dean G. Luscomb II & Sons Middleton, MA 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C c SYSTEM INFORMATION (continued) Property Address Owner: Owner: d"7 i �t Date of Inspection:9'1 7/90 GHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection) (locate to plan) Depth below grade: Material of construct on: _cont metal _Fiberglass _Polyethylene _other(explain) _ Dimensions: Capacity:gallons Design flow: gallons/day Alarm level: Alarm in workin r _ Yes; _ No Date of previous pumping. Comments: (condition of inlet tee ondition of alarm and float switches, etc.) DISTRIBUTION BOX:" !2 �aw rq (locate on site plan) Depth of liquid level above outlet invert: Zero Comments: D -- 9c) X t 1 26 �r X z -o X (note if level and distribution is equal, evidence of solids carrvov'er, -f I C/ PUMP_ CHAMBER: WO (locate on te,plan) Pumps in workingorder: (Yes or Alarms in working order (Yes or No) Comments: (note condition of pump chamber, condition of pumps (zaviaad 04/25/97) re"tkc 4 -' Page 7 of 10 Dean G. Luscomb II & Sons Middleton, MA 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address:F0� ForP.Srt s 0' t9ncov,a,r Owner: S7Mi Date of Inspection: SOIL ABSORPTION SYSTEM (SAS):les (locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods) If not determined to be present, a/xplai/n / _/ / / Type: leaching pits, number:_ leaching chambers, number:_ leaching galleries, number: leaching trenches, number length:� Q 64 leaching fields, number, dimensions: % �ieT� a2� X rJ� wQ e le overflow cesspool, number: a C-4, dw Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.) n 7 5,14S, /.Y 1I7 VeC!/ Q 000 cion d / E l "on W/ " 5 � 4n s' O t CLL) M 10 f o b 1<kV%S 77' 50 n; I 2re4 is G (e-�r, O -Ad rN W 11 5,' �' 'Peh I n, o r rr a o an r a SPOOLS: JQ O are Qn site plan) Number and coni tion: Depth -top of liquid to inle Depth of solids layer: Depth of scum layer: Dimensions of cesspool:_ Materials of construction: Indication of groundwater: inflow (cesspool PR VY: _Nd (locate on Ian) Materials of construction: Depth of solids: Comments: (note condition of soil, sl (zavi.ad 04/25/97) raulic failure, level of ponding, condition o v etc.) Page 8 of 10 Dimensions: Dean G. Luscomb II & Sons %' dleton, MA 1-50 — —4065 01949 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _ SYSTEM INFORMATION (continued) F Property Address:, / or�C S S S Owner: S/Yl�lYr Date of Inspection: 9/I SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent references landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) tobT = 90 L. 804 Fores� V, p„aiovar d A B H �pfic O��K T rt Ste V (ravisad 04/21/97Page 9 of 10 S Dean G. Luscomb II & Sons Middleton, MA 01949 1-508-774-4065 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address�Q4 FareSr/ S , A), 41)(r1er- 0wner: 5;;;17�' Date of Inspection: 9/17 /98 9 / -�- Depth to Groundwater / Feet Please indicate all the methods used to determine High Groundwater Elevation: '/ / ezp µa I e %cs� Don -p- 4/161,7 �t o a re �/ /l% fro a ✓ ) Obtained from Design Plans on record �� t / / wo.IV p OC'[� 4' T,Z)ow Ira, ZObservat on of Site (Abutting property, observation hole, basement sump etc.)B/- �S joeN ,,,,/ Nv SCWh119 Determine it from local conditions 'eR"'p 73u� iJ wa,/K out �t9�f a 6ack Check with local Board of health Check FEMA Maps / f�.,,L� iia S ah �y d+G�h porn �G�7 To /yfQi i� Check pumping records 77,1- Check local excavators, installers Use USGS Data Describe in your own words how you established the High Groundwater Elevation. (Must be completed) /ZZ ,jam G� f/4'%'�li�i� P✓L s� S h , , S ,oc�aArW Drums ,-/r S -Ware be10L-� -'kc, 0' H4 i'gck ;�Uy 6-)0u%V �-�aw :5,? - 6 , t- Grourwl GcJ�4r-r Sepe(-a- -t'cr) (revised 04/25/97) Page 10 of 10 Z/ TOWN OF . SYSTEM PUMPING REC DATE: SYSTEM OWNER & ADDRESS COL( two ,,fc.�( �()q �Fc(-e 4 !�� AUG 0 5 2005 TOV: .;,iORTH ANDOVER HEAL. H DE:'ARTMENT SYSTEM LOCATION (example: left front of house) DATE OF PUMPING:' a-^ 0 S QUANTITY PUMPED: 1 pap O GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER 121111f1fi ILI 10sytoI7 BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIIS) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D V Lowell Waste TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: 9 -C)-' / 3YS M OWNER & ADDRESS . So L� 7F-x6e=�J 5f SYSTEM LOCATION (example: left front of house) IJ DATE OF PUMPING: QUANTITY PUMPED /oc� GALLONS CESSPOOL: NO ---Y---ES SEPTIC TANK: NO YES A� NATURE OF SERVICE: ROUTINE 'EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: CONTENTS TRANSFERRED TO: L, FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) -C-\ Commonwealth of Massachusetts W v City/Town of System Pumping Record1 Form 4 4�M SV BY`W ' I 1 DEP has provided this form for use by local Boards of Hea h. OtPer forms may be u d, but the information must be substantially the same as that provide %fW1 m, check with your local Board of Health to determine the form they use. The ust be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System tion: Left front of house, right front of house, left side of house, right side of hous CLeft r of us )right rear of house, left side of building, right rear of building, under deck. ��u �e�sE- tet- 4�kX�'t,�- l8-✓�� City/Town 2. System Owner: Name Address (if different from location) City/Town State Staten �� ✓ C Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ ,Other (describe): 4. Effluent Tee Filter present? ❑ Yes No ` 5. Conditi n S stem: 6. System Pumped By Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Loca�c nn where contents were disposed: L.S. Sig Zip Code Code jDr-z-) Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 North Andover Board of Assessors Public Access f qO RT1l 1 #� # SSACHU50 Click Seal To Return Search for Parcels Search for Sales Summary Residence Detached Structure Condo Commercial Page 1 of 1 �roperty Record Card Parcal M -)I AM RA D-11AAC- IOMI n PV•11111 !` .,,,,,,,,,,;*., • N.,..+h A—A-.,^- Location: 804 FOREST STREET Owner Name: CARNOVALE, FRANK L. CARNOVALE, PAMELA R. Owner Address: 804 FOREST STREET City: NORTH ANDOVER State: MA Zip: 01845 Neighborhood: 6 - 6 Land Area: 1.36 acres Use Code: 101-SNGL-FAM-RES Total Finished Area: 1230 saft ASSESSMENTS :al Value: ilding Value: id Value: rket Land Value: anter Land Value: CURRENT YEAR 343,000 133,400 209,600 PREVIOUS YEAR 341,000 131,400 http://csc-ma.us/PROPAPP/display.do?linkld=1707579&town=NandoverPubAcc 6/30/2011