Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
Miscellaneous - 81 CANDLESTICK ROAD 4/30/2018
_N O W D 0 J 0 1p 0 0 O O 0 7244 Town of North Andover HEALTH DEPARTMENT �SS�cHustt �'j CHECK #: I DATYJ IA nefi ��I)E:: LOCATION::< H/O NAME: CONTRACTOR NAME: Type of Permit or License: (Check box) ❑ Animal $ ❑ Body Art Establishment $ ❑ Body Art Practitioner $ ❑ Dumpster $ ❑ Food Service - Type: $ ❑ Funeral Directors $ ❑ Massage Establishment $ ❑ Massage Practice $ ❑ Offal (Septic) Hauler $ ❑ Recreational Camp $ ❑ Sun tanning $ ❑ Swimming Pool $ ❑ Tobacco $ ❑ Trash/Solid Waste Hauler $ ❑ Well Construction $ SEPTIC Systems: ❑ Septic - Soil Testing $ ❑ Septic - Design Approval $ ❑ Septic Disposal Works Construction (DWC) $ ❑ Septic Disposal Works Installers (DWI) $ ❑ Title 5 Inspector $ �; Title 5 Report $ A ❑ Other. (Indicate) $ ( ho -I ju Health Agent Initials White - Applicant Yellow - Health Pink - Treasurer ' Commonwealth of Massachusetts 16 Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address *jv, Peter & Lisa Besen Owner Owner's Name information is required for North Andover MA 01845 5/21/2015 � every page. City/Town State Zip Code Date of 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: A. General Information When filling out RECEIVED on the computer, use only the tab key 1. Inspector: JUN 01 2015 to move your Neil Bateson cursor - do not use the return Name of Inspector -TOWN OF N DEPARTMENT key. Bateson Enterprises Inc. HEALTH Company Name sa 111 Argilla Road Company Address Andover MA 01810 Citylrown state Zip Code 978-475-4786 S115 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 Title 5 (310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 5/21/2015 In4leck6r,stsignature 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. t5ins • 3/13 Title 5 Official inspection Form: Subsurface Sewage Disposal System •Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner Owners Name information is required for North Andover MA 01845 5/21/2015 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. 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. Check the box for "yes", "no" or "not determined" (Y, N, ND) 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. ❑ Y ❑ N ❑ ND (Explain below): t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 2 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 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover MA 01845 5/21/2015 City/Town State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 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 ❑ ND (Explain below): ❑ 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 ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ 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 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 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal sposal System •Page 3 of 17 ►• = F Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover MA 01845 5/21/2015 Cityrrown State Zip Code Date of Inspection B. Certification (cont.) 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 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 must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: You must indicate "Yes" or "No" to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® 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 % day flow t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System •Page 4 of 17 ❑ ® The 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 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 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. t5ins • 3/13 Title 5 ficial 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 81 Candlestick Road Property Address Peter & Lisa Besen Owner Owner's Name information is required for North Andover MA 01845 5/21/2015 every page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 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.] ❑ ® The 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 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 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. t5ins • 3/13 Title 5 ficial Inspection Form: Subsurface Sewage Disposal System •Page 5 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 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover MA 01845 5/21/2015 Cityrrown 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 ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ 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? ® ❑ 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? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner (and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms (design): 4 Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): 440 t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 6 of 17 4 Commonwealth of Massachusetts u,pTithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner information is required for every page. Owner's Name North Andover MA 01845 5/21/2015 Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Is laundry on a separate sewage system? (Include laundry system inspection information in this report.) Laundry system inspected? Seasonal use? Water meter readings, if available (last 2 years usage (gpd)): Detail: 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/sq.ft., etc.): Grease trap present? Industrial waste holding tank present? Non -sanitary waste discharged to the Title 5 system? Water meter readings, if available: ® Yes ❑ No ❑ Yes ® No ❑ Yes ❑ No ❑ Yes ® No Yes ® Yes ❑ No Current Date Gallons per day (gpd) ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No t5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 7 of 17 Owner information is required for every page. Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover Cityrrown D. System Information (cont.) Last date of occupancy/use: Other (describe below): MA 01845 5/21/2015 General Information Date Pumping Records: Source of information• Pumped 2015, owner Was system pumped as part of the inspection? If yes, volume pumped: gallons How was quantity pumped determined? Reason for pumping: Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool Date of Inspection ❑ Yes ® No ❑ 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 • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 8 of 17 • Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner Owner's Name information is required for North Andover MA 01845 every page. Cityrrown State Zip Code 5/21/2015 Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Tank & d -box was replaced July 2000,info at B.O.H. Leach area is 36 years old, 10/26/1979, as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer (locate on site plan): Depth below grade: 2.4 feet Material of construction: ❑ cast iron ® 40 PVC ❑ other (explain): Distance from private water supply well or suction line: feet Comments (on condition of joints, venting, evidence of leakage, etc.): 4" PVC through wall, 3" PVC in house, no leaks visible Septic Tank (locate on site plan): Depth below grade: Material of construction: ® concrete ❑ metal 1.4 feet ❑ fiberglass ❑ polyethylene ❑ other (explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) Dimensions: 10'x 5'x 4' Sludge depth: 0 ❑ Yes ❑ No i5ins • 3/13 Title 5 official Inspection Form: Subsurface Sewage Disposal System •Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner Owner's Name information is required for North Andover MA 01845 5/21/2015 every page. Citylrown 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 33" Scum thickness 0 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 15" How were dimensions determined? Tape Measure Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Center cover has riser to grade. t5ins • 3113 Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass Dimensions: feet ❑ polyethylene ❑ other (explain): 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: Date Title 5 official Inspection Form: Subsurface Sewage Disposal System • Page 10 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 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover MA 01845 5/21/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): 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: gallons gallons per day ❑ Yes ❑ No Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments (condition of alarm and float switches, etc.): " Attach copy of current pumping contract (required). Is copy attached? ❑ Yes ❑ No t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 11 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 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover MA 01845 5/21/2015 City/Town state Zip Code Date of Inspection D. System Information (cont.) Distribution Box (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. Evidence of carryover, pumped d -box to clean. No evidence of Pump Chamber (locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins - 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System - Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments r 81 Candlestick Road Property Address Peter & Lisa Besen Owner information is required for every page. t5ins • 3/13 Owner's Name North Andover Citylrown State D. System Information (cont.) Type: ❑ leaching pits ❑ leaching chambers ❑ leaching galleries ❑ leaching trenches ® leaching fields ❑ overflow cesspool ❑ innovative/alternative system 01845 Zip Code number: 5/21/2015 Date of Inspection number: number: number, length: number, dimensions: number: 1 field 20'x 45' Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil Ok. Vegetation ok. No sign of ponding to surface. 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 Owner information is required for every page. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover MA 01845 5/21/2015 Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 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.): t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 14 of 17 I Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Owner information is required for every page. Property Address Peter & Lisa Besen Owner's Name North Andover MA 01845 5/21/2015 City/Town State Zip Code Date of Inspection D. System Information (cont.) 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 building. Check one of the boxes below: ® hand -sketch in the area below ❑ drawing attached separately t5ins - 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 15 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 81 Candlestick Road Property Address Peter & Lisa Besen Owner's Name North Andover City/Town D. System Information (cont.) Site Exam: ® Check Slope ® Surface water ® Check cellar ® Shallow wells MA 01845 State Zip Code 5/21/2015 Date of Inspection Estimated depth to high ground water: 4 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: 6/4/1977 Date ❑ Observed site (abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health - explain: Design plan ❑ 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. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins • 3113 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 16 of 17 Commonwealth of Massachusetts Tithe 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments 81 Candlestick Road Property Address Peter & Lisa Besen Owner information is required for every page. Owner's Name North Andover MA 01845 5/21/2015 Cityrrown state Zip Code Date of Inspection E. Report Completeness Checklist 0 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 ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5ins • 3/13 Title 5 Official Inspection Form: Subsurface Sewage Disposal System • Page 17 of 17 • Summary Record Card generated on 4/7/2015 1:01:34 PM by Karen Hanlon ' - Town of North Andover Tax Map # 210-106.A-0109-0000.0 Parcel Id 17253 81 CANDLESTICK ROAD BESEN, PETER 81 CANDLESTICK ROAD N. ANDOVER, MA 01845 Page 1 Class 101 Single Family Property Type 1 Residential Zoning2 1 Residential Zoning3 1 Residential Size Total 1.31 Acres F.Y 2015 UB Mailina Index Name/Address Type Loan Number Active/Inact. From BESEN, PETER Payor 81 CANDLESTICK ROAD N. ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/Inactive Bldg Id. 17621.0,- 81 CANDLESTICK ROAD Last Billing Date 1/7/2015 3170292 03 Cycle 03 Active UB Services Maint. Account No. 3170292 Service Code Rate Charge Multiplier/Users MISCFEEADMIN FEE 0.635/8 7.82 1/ WTR WATER 01 ALL METER SIZE 57.00 /1 UB Meter Maintenance Account No. 3170292 Brand Serial No Status YTD Cons 36388126 a Active b Badger Date Reading 3/11/2015 320 12/11/2014 307 9/11/2014 292 6/11/2014 273 3/11/2014 260' 12/10/2013 248 9/11/2013 236 6/12/2013 2.15 3/13/2013 199 12/11/2012 184 9/13/2012 171 6/12/2012 148 3/14/2012 135 12/12/2011 124 9/12/2011 112 6/7/2011 91 3/8/2011 75 12/9/2010 63 9/10/2010 50 6/7/2010 20 3/9/20.10 4 1/23/2010 0 12/8/2009 3650 9/8/2009 3630 MSG 13 6/8/2009 3600 MSG 11 3/16/2009 3560 12/9/2008 3544 Until Location Brand Type Size YTD Cons ERT HH b Badger w Water 0.63 0.63 303 Code Consumption Posted Date Variance a Actual 13 -12% a Actual 15 1/15/2015 -20% a Actual 19 10/15/2014 46% a Actual 13 7/16/2014 7% a Actual 12 4/11/2014 -1% a Actual 12 1/1712014 -42% a Actual 21 10/15/2013 31% a Actual 16 7/24/2013 8% a Actual 15 4/22/2013 12% a Actual 13 1/9/2013 -41% a Actual 23 10/15/2012 71% a Actual 13 7/16/2012 22% a Actual 11 4/14/2012 -10% a Actual 12 1/17/2012 -39% a Actual 21 10/13/2011 23% a Actual 16 7/20/2011 30% a Actual 12 4/13/2011 -7% a Actual 13 1/12/2011 -54% a Actual 30 10/15/2010 78% a Actual 16 7/15/2010 100% a Actual 4 4/14/2010 0% n New Meter 0 4/14/2010 0% m Manual estimate 20 1/12/2010 -33% m Manual estimate 30 10/15/2009 -32% m Manual estimate 40 7/20/2009 0% a Actual 16 4/29/2009 8% a Actual 14 1/20/2009 -38% Commonwealth of Massachusetts City/Town of a System Pumping Record Form 4 TO DEP has provided this form for use by local Boards of Health. Other orr information must be substantially the same as that provided here. Be ore 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 Important: When filling out 1. System LocationCeftfr—oin- left rear, left si of h use. Right front, right rear, right side of house. forms on the computer, use only the tab key Address c .�y , to move your. �i"�� V�- cursor - do not use the return City/Town State Zip Code key._ Z System Owner: Ills "L— Name Address (if different from location) CitylTown State/" c.� � _ Zip ode Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: Q Cesspool(s) Septic Tank Tight Tank Other (describe): 4. Effluent Tee Filter present? 8 Yes No If yes, was it cleaned? p Yes No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location contents were disposed: L.S.D Lowell Waste Water of F 5821 Vehicle License Number Date -16? t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1 G' Q a �� yerr.fY.. �::��.. �.: G�` l / 1\ r O r TMT"Ir-6"Tial Ch,,CK LIST 0 c 1. Instance To: //��� � a. Wetlands b. Drains c. Well 2. Water Line Location 3. No PVC Pipe %. Septic Tank a. Tees - Length & To Clean that Covers - b. Gent Pipe to Tank - to Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach Field or Trench a. Dimensions Stone Depth c. Capped Ends d. Clean Double Washed Stone 7. Leach Pits a. Di cion b. Store tit C. Spla Pads d. T s e. e�,nt Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal 9. Final Grading Inspection /10. Barricading Covered System ll.- As Built Subadtted a. Lot Location b. dimensions of System c. Location 4th Regard -to Pere Test d. Elevations e: Water Table �. t It.. c .PPROVED DWPE PROVIDED f - - - 9.ea % /V Title 5VI Reg. 2.5 Fail Reg. 6 ANDOVER BOARD OF HEALTH L oTsle DISAPPROVED DATE TIME REASON Tie submitted plan must show as a minumum: (a) the lot to be served (area, dimensions, lot //,abutters) (Planning Board files) �( ) location and log of deep observation holes -distance to ties (c) location and results of percolation tests -distance to ties (d) design calculations & calculations showing required leaching area (e) location and dimensions sf system .(including reserve area)* f) existing and proposed contours g location of any wet areas within 100' of the sewage disposal system o t- disclaimer (check wetlands mapping (h) surface and subsurface drains within 100' of sewage disposal system of disclaimer (i) location of any drainage easements within 100' of sewage disposal system or disclaimer (planning board files) (j known sources_ of water supply --within- 200' of sewage disposal =.system or -,disclaimer-. (k)- location- of any proposed -well to serve the- lot (100' from leaching facility) ( location of water lines on property (10'- from.leachin facilities) location of benchmark i driveways - garbage disposers �Ino PVC is to be used in construction a profile of the system (elevations of basement, plug pipe septic tank, distribution box inlets and outle distribution. -field piping and any other elevations) ( maximum ground water elevation in area of sewage dlsf system (s) plan must be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Sega -tic Tanks ell (aa Capacities 150% of flow, water table, tees, depth of tees, access, puinping, Cleanout c 1O' from cellar wall or inground swimming pool (d 25' from subsurface drains ?ail OYI _Distribution Boxes ;g.14.1 ;g.14.3 ;8.'14.4 .- -14.5- g I4. -G' g.14.7- ;g.14. 1 /� Slope greater than 0.08 (b� Sump Leaching Pits Leaching pits are prefer where the installation is possible (a) Calculations of leaching area (minimum 500 S.F.) (b) Spacing (c) Surface drainage 2% d ,,Cpver, material )' fe r cY¢c11pta 2 s t� e- d( ) "' w, 42( !Maching Fields 3 % Greater than 20 minutes/inch Area (minimum__.900 S.F.) Construction of field �Surface" drainage 296 ale -20' from• cellar :wall or inground swimming pool Leaching Trenches (a Calculations of-ching area (min. 500 S.F.) (b Spacing (4-ft�n. 6 ft. with reserve between). (c Dimensions,-., (d Cons'tructiori. - (n..�'St one - ('f)=--Surface__drainage 2% Downhill- -Slope �= a Slope Y to be -shown b� y/x A 50 = �to be shown Pumps (a Approva-1 .(8- Standby power Al "too A J! .r., t, ` �' ,�' tea.' �� '� «r r .. � 4�`� , � r }�_�' � J j`. '.r+ Al tKI iZ t t I.A v. is t pits it Nzw Oki --4 .31 -va L IZk, k7R in W 031 ilk Woo loll gg ANt. -r-,: n,, 77 4 Wes,, Q Q Jt" Ogg ^ 1A a NOW, sk, p N X 4, �, tl� I fill A NX_�1;11 m 14 1 lll� . " - I I . , �. , . , ... ,.�. "' i � , ?. �i , . . .4 , - - 4 , 4 , % � �t , � z , 4 ,1 " �s;� . ��, . , ..� :-, I -� . I ��'; 11 �.4,N.i."7 �::", .": I"�,..,. ,4, , . �, . , i, i"":i �e I'. I ,A, -V I It ,r'` 4�11 . .. 11 its . 7. �t,4 "&�. .,. .,i � .!. , - � � f . ". I �. . , � � - . - � � ... . , -.1 I - :4�, il...W , ... ..k ,z �.. � : '. �.,. 1;1 ..l. I �111 ll , 4 . , � �� I I. � �i , , . - i � - I -,:,., :."ii , 4 , i ii , -, � V-- - , E-'. 1;,� . ! : � - ,��, it, , , . I 1:� * � L. � . , I , , �., . � � �, " t 1 4. I' �, .4 ,4 � , .`,�"I' , I �,; � 11 I J.�.. I I I '. . � . e ., . I .. r , �'! - � " , h I � ... ,:.; � - , . �� " I 1, , �l �aK �l . . ,;�� I 1�' - - : I I . . �N� . � . .,- ., , . � + A � � �,� I-'- .; I "'. . , , I �;,; 'I '� I . , " ., . . t ,F �,� ... �, � \ It - � . ." "!.. . � k�. . ., " _ , . . . .. ., / ,.-,i I . $ j ,� .1, '. � , , � �,�- -,♦� ,-i , �`,,,.1., ,�-.- � � ', 1 -1 - - , � . 1. �t ;� ) i , v . . I �* .1 I 1'. �l . i, , L x I.- � . - . : , � 1,.�, , : - , I .'.. .1 � .� . "I � �� - I � . ,. 4,.�,�.P.� ,j f )� -1 .� -.-. " � -* 1� 2i, ,Z� . % I I I �' J�, .� � .� , , . i-, ,I l f 1, . , �, .- - - '- . o7i.? , , ,�� '. � � 1. - .1 . � , - . , , ...,- "_ . �, , , , .. ,% . , .. " , �, �.,j; . . ". ;.1 I ... , I , k -1 11 "" � � , . I (� � . � - 9,0.11 , t!. V - " t 'r + � . .. 'I g � , , - ._ " I . A, . 1. , . ,�r , �, . * - - - I " 11 - 4, t. �,,� �1.1 ..�, `� ��,�' 1_� " Jfl!� , ., . , . �: N . I , : ,�,�t�1�1.11.4 "j, .. .,..� c 4, � .. 11 , ; 1� m A" . .. ; �. -•� I , - - - - , . - �,� " - - 1 .- �'�"f, I , ; ;l A� � �'_�k i, ., i I , .� " �i �. 41:�F I I'll . . I , 2 , . 4.1 I l,'11; .. Ili ,-..W,% , � .... 11 I � ,�.. " ,. . . .... 44 . .. ., �, . - , I � . . . . . 'i. v , . � " ,.s 1. . � �,�i i,i, ,1,,, � , ` , ,� � I , - w � m� � � 1� "I I �, I � l..-, �;,'�,Tv -'�Z�� ,I i - 4. -. I I I , 11 '), 7. %, .. , ,j�;;, ��. & �., : , "': i � , � i� �'.�';. _�,,. ,,, +.,� , ..... . - All"i V . .� ..... � - 'I., � , , , k - * : . �le , 1� , , ,� . . . 1 61- - - . :i e . ., - � . . , % � 1�\, ,,� ".v �l , I I ,--, " , I I- , , ,q a , i. . �N, 'N t � . , ,; .-N i . ." ; I '. � I ,. , , " . , . a I - C I . " -, � , * . , t . i � � � ": I +. . . " . ,�., . . , " * . Y. 4 , � I 14 < .,\ A 1 r , f : . � . � J�� 11 I- 1, , ,j , .1 ;, . lw, 1! , , , t� , , + � . ,�'. � . ..� " .1 I I .i, �. t� " *��j� 1 " - ; � , , � 7. i. ll�. . 11 , .. , _� .�,i 1'. � �� I � � . . 4 �. - : - I , . � . , , i �� , I � , � . . .. .. I . \ 11 .1 ,. ,4,,j � , , 1-4. , ,Z .. " I , , .,.'. , . it � � �� ZN� ,(% , y , . %, ; - ,., I ... 11 I 114 " .1, , I i* � - .F. I " ;X; ,N) �. I .14 .j - ; I t s, � . , � . , ':� . . ,�,' % , I , ; . 3 . : �.., � .... I I , -1 : , It, .� , :. , � �� � " 11 � § . I . . --i :�� I � ,�!. � . • ,I 4.� - . � 7 :.,:�, - � -'li;4 -4 . . 4 '. ,.-. -- ,� , , -. I � ` - " � . � - � , t �.� .�T, � " i . " ll� � �1� �� �_lj , I � . Ns� , . . .. - - - - - . 'K 11 il - , " � , �t , . � , .'� Nt� � - ., '.. 4., -, .. :._� , .� � . . - ,";A, I I �11 '! i- I I.T ,;"t,16" � I ,I -6 , ", �� .I . .1 I:z -, � I � . I 4'!. . 'F." . � , ..... ..., , " .i . .1 . , .. � . 9,! . tr - , � . . i `� , , a , �7 ., ., �_' j�:,l . Z�R_ . . I I - "') � I � I , I ,� w "W .:,, , ,4 't �l . . q " , ,l I I - I �. Z* ��, 1. - � � . . . , . . . . , . . , . , , , . - �l 1% , �.,j N_ � � � % . . . , � NZ , . - N. - I'... . . I , -, .f-"1�..� � . . .. . . , .1 �l . , i 1. ., 1. . , I . - e.: -, -1 I .. I �, :M. - ,,, 1-1 . . 1, . - m., I � : ....I- � �,o , 7, � . ., . I . . 1. , .:?�.�!t:,�.,� ��,i: I . . - . " , � -�') S�, �D , 1-111", " u - � - I .1 11; , � Z, ,�,;4 .,. I . � : � 1� .. - ::�,. , 4. , �6. ,; I " � . . - . . V�. i , . �� � _. . -ky 'I- 11 ... . 5 - I ., . ," " , , ,�Z� - , ,� , \.' , , I �. I . �6 sf�'J �_-, �,,� �74 - 1 , - . �4"l . . . - it � , 3 � I � ,��.? 1. � � .1 . , , ". �. 1'� It, , i ., ) I I ... . , - 1. �. . .- - tli f L. I . . . , -1 - I I I I � * ,, �� l .. I . Im �� -4 - I 11 . �. ... . , . .1 I . ,. '14; . ".;.114... , _�'�-k.� 'i, . , ) �,-1,� "v ,,�,, I * , i ,�,�,J�"";f, * � ; - - ,Q,�, , ,s� - , ..� . _�,&. J . , � I 4 . " _. - 1.1 - I .Q� - '. t -,:J ! - , 4�1' �l ., -,� - " " ,.;� ,v �l , ; , .. S, -�� ,� . ." .4 ,nk - Kff � , . , , I �� . ., ..-�. -, - . Ni. I , �'i •I . . ,. . , , ". � .7 , ! I I + I .� I . I I N11 . I , 4... . N.. !'f . I " , - I . . , I .. , A �\ � ,�N , I - - i , m -Y , . Q , ," , _;�, I I �. , - I 1� , I I�N , � f � � 1, , , - ) . - - � . '. , . . I m � � .�k I-, , , i ,j t - . I , . + - 6.4 , `Vi , - l N k'3: , I . � I " , k , I �\ - I., - � % � \j I ,,., - 1p- . . 'I I �l j � - � . . I , ., ." 4" I '! , -.1i.i � I . - I . , . . I., . � IN I �11� I . , . 1 � , . I . � . I . .� f_� . I .. I . . .. .. I � . I . � . , 1, ., . � I , . , . ,� I �- ;4 . - . . , , . . " . - � I / . . , " I. IX . I I .�ll *!,." .i.l' . , I � I I . . .. I ,�� . � . .. - I . I . I . I - . I . . . , ,-, , `� ,1, , ,� li"'!,-'.. . I I . , r4l., � , "' , , , , o ., __ . I , . . I , - �11� I 'I '. � I ow . . �-,4__ . I I . .. . I ,. - �. . . . .:: : ,_� � .! I I , , I , -S}- -e - + . I .. �! / . .1 - . I., I , �,p.o .*. . '. ,;:", , - . il � ;� �,_..i, .1 �', - , . : :� . . . . I ..L_.; , . , t" . " t; I � � - - I- , - � , , I - "II .11 I ` - . . ! , , , , I � I --- - , "' , 1, '* O .1 I 1 �N4" 1 !N � - - - - - .. - + I 11R� I 0\411 I'll I I I i I � ". I "'.; - I . ,� ... , N� 7 - I -_ I '. , w. � .�, ��`f. . . I I :;�;.-�-, -, �:... .�,-_ " ,.,,,* . . I - ,. . , . � I , �'ll , , , " , . f � 1,�l " � " I -1 , 1:, .1 , *,...." .1 i M 0 I I; " . �. , �,)',.`�!.,� "i �� - , 1 - ; I ;�,�, � . Wo7 i ,� ,...�,*,Y.. � ,.,�.. � " " � , I , , I I. - � .. w. , - .� iim - � �.._' " ,,:�, , � �l , - ` �,-;� _k_.41'�",,t�r�". lekd� - . .. .§,�� .p..' j�, . � , q, 1. . I � : 1 �. "-.�. , ,-'-_. �.' ,%�t, , :1 jr:.,!,.. ": � ,,'; . .. 'I." -.. ��".;� , � . , I - I C�i!; _. �111._: .. {•+i , 54. - , . ii .., � , . ". - - - , - , . - - , , _ "' - 4.t# '. , - . .,�, - , .; " � � W'..._. .� � � �, � � - �;i'. , ... ? ., , t , * , - . A . � ! M . , "' - Ili , . . � 7 - - I- 'i �.: '%.. i - -t- q, - "' '..,`-'-',-,'?�,z��;,', :!,%�,,' . ", . I ;. . ". -. ;, �,_, , :'_.. _�, , . ", , - i,.,.'V , , , -, " " , - , � * , , . .1 ii: ��,l � ,_'., .- - -_.q� , � ,,� 1. " ,-. , "I.,, �� � � .4 � � . - , .; . - ! -I-,' � - - -5 � ." - i - " �,, , 72 �� ,:�-, '?, , " ri •i ,�;; , , , " , ""; - , . 'i. .y -, �,J, � .1)- , T � I .�i... - , . I , , e. � I -. - P, � I 'It ,, . - I "', 4� .o�,,nv,,451 RzVfii .,&��_��fl:j"r, I 7 , t , ?AIO��,4��.,.7 .�� �! , I I. .1 I'. !*' , lk , .S;�,,??,., ,�"',,__ , I __., 4 1;; - - .s: c., ,R� er.� - r , - ��T�:�!lll .� 1, I . !.� 1. - ., 'r& ,%'�.A,?� - - � � " � �� �"j, . �� 11 ; � �w - t� , v F. ,,I' � , , , _., � '. �_ x� ': � '_� , , � � I ll� 1_1+� , " , L , , I -,I;. t- ,: - � " 1 . , $;,��", �4�1,�,'.!IL, -;"g. , � , .',� ,. " ,%, 11 I.. . � ., ., . Am, .1 ,�! � I'.- f , I q ,W;!4 It I'! �11 " ," _. ". 4-.. . I . ." !, _�� i, 5 , 4 . If p !r� , .,; ". 4 � , , " .. . I , ,Y * It '�`.' , v . , I , "_') � : .�..! ., , , , � . �j � ox�!�,,� ��N`ll "r " ��.,-F�,,,�.7•t.-• , :"-�,f�.��,�i-;,�.-,,s'�,,-+,�.Z . "I. ..', 11 11 , . . I � Z 1. � , e-� ,Fj,.!rj .? _1 --- , 1 -k. q;.."�, ,,- � . , .1, ,F , . � I , t, %AAZ, ai_c ic .1 I.., - � � I � I f` ., 1, ;1:11,�l �*Z.� , ;, - -,L - � " 1.11�1' 4 ;,i � , .1 .4. ,�x � - * . ", i�l . , , , , " ,_ 11 .... 'see `>, li�ms ` , , - , , � . I I &� , 4 if, , - 11 . . . . •. Y. t -7 _12I. -TAW . . � ` " *11, &Zlnll L, ,- - , x - 11 z. "', �', , . �,... . . - I _K, .� !k� - :. � �� , . EwRi -1, 4 e 7. - i�tl& �lllvl;*.11� , I - t! �;u . , � " � , 4 _1 I , . v �. 11t,.,:." 7, � . - -1 . 31 1 , , 1_. . I. - . -�pp, �;4; ,l , , ... , � .. '. q & , ykj& - , , ,".. "_ - , . -t. -. ��, t,",� -, �� �,-��. " " - � � �.- ,; - � �" 1 -.1.,�,", �,- ,4� �� ,,,6# .- . . ;; - ,.. . I - 11_ W�l �wd �, . � -'U.'' - '� , 'A�A _i, "',-,' -� - A�",'��`�'*i+1.11' " :� ` ] '-.:-`� ", I- t�4' � �, - O" '- -, "' ` "' .J ;, --- - ".� .,; � I " i, . ., ,3 �,'�;, .0. , I - -� n_'," �. 1�1i'l;: i 1',/ ,;l -�� - . ,.bl i�;�, ," .,'Z� ,�' ,�"' 1-171 ., . �' l.;.i,iA"_.l. W, ",.Vlllt� g � . �;_l ft,`,,.j�l, _ I— � "..I ,;if,," -,.-,,�,�,,�' Ff_�% " �! � H - V, . ,. '7�," � I F �� I I .. "' �.�. I ll� - � 4V : -1 1. . � 7t'�,'A , Vl�i,� T";-,;. - "'S .11,111, IX .11 .., - 1, , S., - , , ,,� tw'_�,.�� T; - �1_91_ - �, - _V .��: " ., - . ,� 44 � "'�.,.' `� .. L - .;",4; ,.-,,I,::-�;��, , _U, 4 , � I 1,,,�i,'.. ��, . " I ;� .k . ... .1 �, Y % ��'��.,',���'r-��l,',,".4,�'�;7v - - O . of � I , 5 - . �11 � - . , ; -1. �., . �J�, .- , , 4 `� A- , � , '. i� '. P,4�J .1, k.,'!� Y'N k- ., �i, ,��e�,: '.,-,-v- � 'i ,� ,"..q ; I _ - 4 .4� .� ';' I, , .i, - .. , , ." � ., ,�; "'.; ,,; f �, � - , - Y�i N -- - i --, , " ., : C I m".,.', .,,�� . � .�,. a. 1 f"-.;, � t , 1.41 I - �l � .. .. � _* v, - . -. . - , , A . , .. ( I ..' . � . . . .; , , �j V�7 "N., V.. � " � I . 4 W, - 1, I - 1. I � , - - - '-, --- . , - 'I. c� 'i, � I it� , * i* .". . - - . . , - , X'L " _�,,� I � - !� � , C- I ,�Y..`lo "i, , �" .1 . � . " ., �l .1, ` - , � � lvk�. ,!r, , I . .; �� " tl.", . .. �� - I- , , , , -� .. �� , , K L , _V % . I , I I - - - - m v ,�. ;�-_�. -- . , .. ", .�7� 1 'V.�. ..w " � ,�, , :4",f�,��,,�,,-,$,*-�,t�k,',-':�,�'4.,t.�2�144�l,:�-,, . 'Pr�e t, .. , -1 . . ,..,;,._,:_� r � m' " , , , Rl - ,--, , "' f,� V � % ; , , I I 1_,,;�, I . . - - . .�1,5 �,�,,f .� -,. '? �.I)r i� nw ? . _�;, . ,,�' , ;z.,- ,; �_m � � - .�",t :.-��;I,�,, .�'. . , , � , �". ��_ _. , 4,j . _.� ,, " .� , . . n � N � " , -�,: ".., .;. .� . � � ". ": % -, i�,�,.,�,', . _ . ". I 'k. � �.- ., . , � , . � I 1�� t. �, __ ;� I , - .. I , .& t.. _j, .. - I . .11 .1 -- - , , * - � , Orz�, I *1_1 I � , A. . . . . . . . . . . . . , k . - �,�!, ,.' ".- +` , �'. - 0 . . . , , ., . , . - . , , - . . . . . . . . . . . . _ , ,�, " -, � I X. , . '. "lil ., . � , I , � " , ,:.. , - � � ,z ; �� ", X ., �!. 41� , .. ,,, _. . ... 'N I I . � , :. , + " - , - , . 't I \�v 11 4 : , , , �"i.�,'v�,.,,' I .!� . 1� .�', , 1. "l, - � " ". -'." � 1, * I . � . I .., ", . el� - 11 - l -, , , , . ,!.;' I ef,�! - - � � , `�'�,�,' , " . oll 1�:� " , . I �, . ,� .. IN'S k" .. ., k. '�� .'!.' .4, .� , - . I , I I . "N'if-I ,._�, -�..,.,� --� ..." � � *,%:z!� . ..... . ? 4;0?� '' " . � , 4 ."g�-e&# . :�.,,.. �� ��,� oi ":�., .: . v , ;'! �ftl �P , i � '. 4 ��", " , - , , � - � , - �:: ,7 , " --�, I - . - " '. . , I ..; " - I . , . , - I- �..i , * � , �,��.'�', ,�,�,i4ali , . .. I , , * � . n; ` , , , - .., ,S4,- ��,- "4 � �4-. , �!N� i 3 , ., " �`T , " ; ,�� ,., �, ,��, .,.� ; : , i , , ` � .I , - -��,,�`�.`., ." , ,�O, .: I ;..., , . , , .,��.PNI " 'i * .�:, - �, .'�,��_ " .1 - � .lil+� '. . `� , - -, - " 11 �1� . � A .1 Z : ; . , A', . 1. t, .." _ . , ..�!.. ,,, 1 % .11.1,11" . .1, �.. ,�P :,,l�z, _-, , !.. , I �. k.a. .. ,. , - 1, �'. , . - . - � . . � - ... . + .. . _. . - I . - - , -. .. � !.� "a. " , , - �. I �'l - _*4 � , ,;�� , , . , , " , , " .1 �. . . ,� _� . � �; , . , , . , , I - �4 4_��x ,� __�: , , 71',.1,4'�!14. , " � . :, . , .1. , -, " * - .4 .: . - , . . t,' " � ., .� �, , 11 il -1 1� �. I i, i.,�; - ,- i,_��-�.". i , "' - .;"- -- . ., , . .k il� , � . '. , - �� '�5i�: 1�4 1��_,:,i ��,� ;� .� .-, ,4 , . . � :t � . . . .. . . , : .., ��'. �� .7 ., , , j� '. I", . , t � ,, I - 11, .. rl- .-i., - ,� �.- � �, " ,j� + , , . "."'l- -.., I - Z ... ... :. -� � -, " .. ;,�,�+.' . . _. I , , %.�: I, ;, . . * " � ". � A . or ,_ ,.g �l , , " � . . - , - , , - , I , - . ell, - I I .. I ,I- 11Z � � . .. . I I . ;.�, " . . ., R, .. " - ,q l A* , , , * , , lz : . _,_.., . .Is , I .1 .. ,. , * z, I � . " p I , - - , + ! _ . . . , L ,. -_ .. '. , ". I � I ..� I . � .. � - '. . .1. A.. . I ,� . . ,�. , . � I , , � ` �Ille " . 1-11 O '4el , ': ,�� �r ill, ` , . 4 i -,r ,f. � I . .3 ". `�4 I . I .. . , . . . . I - - � 11, . ", " 4 I I . � I , � .4:�,. 11 I 11 ".1 '! . I . ., . . . , . � . , . : . . '� . " �, � � , A. . , �` I . I . �,_. . ." ". ll��.,_`f, ,:, . � . , , ,�� . , ,� - , I . _ 1�* , , I � , , I 1 i,,� a' g -1 , -� %` .1 . � . � e-. .z.,,-. ., ,.�,.. , .. ;, " . . . .;, , " - . �.� I ... , . . 1. - , , - � . -7 . .. I " - 'SZY o I 4, �� � - :n I � . : ,,-,*- ��?-. . . . ; ,,,.� -A. -, � , � .,. I . . . _( ,�� � , r , _.. + - , • , ,.,,�� , . ,�',t�t!;:,�,.,�Z� TV, .1 I . , "': _ , � � < , I . . �. � �_r .. " ,.1'7 I'*-- I . 1. � � , , . . : . , . I I ... ... I< - - - � I . . I . ;, , ! , . � - . . . . . �_ , ---' _ - - - T. I - , - I . I - - '. , � ,� I � . , .� , . C�� .� 1, "' * , . .. . 1. .i.6, - .1:" . , , .. -i, ;,. " - I ____'. , : i..',(.j�,nl � , w � . . f �, " .. � � . -,".- - ," -.�.; - ,� I . ,�, , _* , I I , 1-1 . . �%. , .... . 4 . i! � , � , . ..;..".,�. . �_ � i . " , . � . � I 1, , 11 . lj . � . V _. I . J'. , . . 11. I L, ' . ., - ,�� .. . I .1 Vr - : , ,,� .. I .1 t�, . :, , --- il ., . LLjk.L . . ) '.." I I I .. I � �fv ; I 4 , - , , . , , " + , I i .. . . , - I � . " ."'� . '. L . '. , . I . , ' :,:: ,� . I I . 1�� .... . '. , ; : .. �L ., 51 , , ... . I . w i' '."� " ' L ." ' ' . ], ' . I : . I .,, .\ , N . . .:, . � , t� - L , V " ii�lk - - "L . �-., -. - , . - � , , X 4 ��, " " . . , , � , ; , - " - L 'f '.. , � , , , L _.. . fq .. ,�.!, . . 4 p , 't . , � . . -r J, � ,, %, , I � '! L- , " .�- I . 4�1 "I ; . , . , , I , I I . .. ' ' ' ' � L ,. : ,. ,* - _ - , IS4 , �, . ,, � -,e,N I � , 1! . , I" �;�,� , 1. , .1 . - _� "', � . t I .* , "'. , , , , f.� i: , . ! 1, . t: . I ,11 , - , . - I �_ - , . - . 10 -1 \�) . ' I .v . , , �l . . , , 11 , _ , '.' - - _ . . . .1 I , L : A " , , , � I --- '1:.l ." "It \ . , . \. X . , 'a ;' . �'. 1� - .�. ` ,; . 1. , ! �, - ' . . . . L - 4 , -.�-, -e4 - -,k '; _.-, , I ;�; , - - � . . . _ :.- , ", .. . � . " . . ., . . L�� . * 4 , -� " .�,. . , ,. - .,q , 4-1 , � .., . .1.1 . 1_. I � . I ` ' " , - i, - � . � . � . . ; ,�t . 4 " - , ,.�. ,.; -, � 45�N',�, .. " . , . . , ',I ; k" �k,* , ' � ,14, � .� .�.�L . I � A"I i'm I , �, I - ,: I . . - K , , . . . . . , . , L. ;, " '. L ,W, +,a., , . 1, . . , 'k . -s' - ., .. " I - I ., . :�, � " . � : I., ,I•L, . � , _ _ I jl,�, : ". . �;. - � �,,�'j - I I , _ % , , . _� , - � . '. . , , - 'ji ,� . " * � � *P � A,',� ,,.+ ,� - , A '. ., ," ,. , i �'. �, , - .. .. . , - -. , , _ . , ._ . .� - ,:_ - ,,.' . . . : , I . - . '. ` : � . S� , ,:V', . k, J� ., f . . . , - I ., , - ,.V, . f � . .. - . . , . . ! Yk � . , --- .. , I . - . ,� - w " , , 1. I ,.� � . �: . '. �- ,� �7, !-� ., : .� , ,�, , . -, ,- •4 , �l �R , , , - . I . - , . I \. - - X I . , . . S. : , , " .. . - 1". - 1�1 I . � -,- . , , :, , .��:t,' " . L, ., -V - '_:�,�.i,!� , _ , T t: - , % . I 11 4,t : � , k ,� , .%, , - , : *;�.,,'.+.l - . , ,• . I . . � . I , s . _,� . . - - i � ! , 1� , - , _ '. � . 1 7, iz,t� 41 : I � �411 - - * \ , �' , 1 f- � , � - � * , . . -1, - .'R , , . I . , � � *'-.� . . . � I , - I I � . . - - , . < ,� I 3 ,� . . . ..!.§ - , - - I . i. , . - . , + I 4, , k 1, .1 1, I 1. � I "I. *�/ . . i�"_V.:.,� -, lz ; L... 1, . .�, ,,, .. �i I ,.,� :; I .. , �! . .- , '�� .,%-.�, '." . - ���,,�� . , . . - I .. . si, I I * * . I . - . - .". .l.. . . # -,- I ." ., , _+ - . ,:- ,_,�_.�:, _k: A - lim -- it., �l . .i� 'I � .I : � . ; . � - . -, - - . Tp�-�,A�.,* . , . . I I - - Rlv! . I . i . . . . i . , . �., ,^l, I t, � . ��,'." V . . -;,4.... 'I ; '�: - :" -.1 � 1. -P. ; ;? ..� � , ,l. �� . .� � �: ": 'k, I iff� 'A � , , - - .I . " " I , - � 1 .6 I.; I 114�+",' `t'., _% , . � . . . I , . ., .1 , - I Vi I "-, , � ...�., -; , P, . . I � . .'. Z�, . .. ll'.� '11� ,. . " � , ,,_ t . .,,� A � - - � i v 0�1 - , %, -�,� -1,; I . - - t,�_. , ., , 1��,%,. � .. -; " 55 I _.Y,�_). �l , . . I . , , - I- ,+ .,� , . I �761'! -c,- �, . 1� , , � . .Y , . , � , .. � 1.4 , __ - � . I ,�,� . I 1. 1711_1� * " , . .� . � �.. ;, � , -A 11 t 1 , . i, � .. .. ., : �%i.. ,,�,,',-'�,-,�'��"..��)."".,,;- " , ", �,.. , - V. . ." el ,,c , � � .- ... "! ,,� ._.��1_1�71�11 t,,�, -, . . � , � ., ,*..�.�'!� . - - !4 R 1 \ . ,,�,,�,,, .� ... '. . ll�� - , , , � I _1� I A . - - � � .el I. � �1. J. I � " '. � ,,:,. _t . � 11 ; , I , � " , ..ala" ��, � � . � . ,. . , '. ,�, � . 4 " 2, . '. .:, � 1 k- 4 i. I il � .�. , � I . � ,� , . � , I . . I I I.M -!, . � . - � .k D , , I � .,. , . �l � , _4 , .. , i., ' ..L . . . . � .i ,�i'l, , � . � -i � I ". �� .. .. . i � �., 1. �,', . ;. L L t,� ,,i).��ii?�., 4 I , - � :t I , "' , " %f, . , .,�ll � .��.�� ..: - 11 11 . I.. .,� , Is . I , , , , .,.,�, .r� .. , , � �� ': ". "._ ", 4- .% ,�4. - . , . , ... _:..,, 3 " . I . , . "'., 44P I . , 1, . I , , I -7- .1, , ', . . � , �7 ... , 11.41. . ,, ,� , �� �. I . �1. - " I �, .. * -.1 , . 1 1-7 1 1 � , � . - I -� ;. . ,,-, - . , . . 4� " , , -, - :�j ,f t'; " WX . , I _.� I.,17� ll_,�.W, 7 ". � . ,.�. . -.i , , , , !, s . ,t I I "I -.1 . . I- . , , . . -!.."i � � t', .. 1 4 1.1W,111 �l � I I � I , . � ,� ,+-,.,:-" ,-.�'. I Z�.. I ... , � ., - � � ,,, �11 . 1 , . 1. , 1. , ,: � ,�.- I I , , . - , . ,,-,-. � � "I , Y ;.. � � _ ; . . , , , , , '. � � �"R , .,. � , . .1. -. , - I , , �, . �� i� , � , , �' . , . , I I " " ., . . . , , - Loz - , ,�: , , �; .,'�, !: .1 , , . . - , , . �. - , . .. . - . - : '. � ,-'. , I I _. L : . , I . I L� � . It I I � .1 ,t�, . - . _ .. � , I . . . � � ". ,,� � ,,'.�, jr..Xl"�, . 1� �� .. . ." . " " , - � . �, +k 11" , �, � .. - , ! .4 1 : _: .., _� I I � - -I � - . . ; , . . , " -1 1". '', -, I `,,o'A 1, - I I .� It, - i. - . -77: :.� .. ;*L' - . " . 6 Nj .,.- , ...� 7- 11 T� . "sk �% 1,- . 1, "I , , L _ .; �, , I - . � I. I � l.. - ; . .4.� . , ,�.� t . rt�.,. ��.,., " -. -, ,. . ,: L , I I ,:,!�,�. . --l'4T.� , � I.. I , � I I , . . "' " " ': �i�..,,:, - . . ., � . -11 L 'L ,' �_' ' I . , l . R." ... i . li... , � , 1, �,.,. 11 � 1� , t . � �.. . �. ";.11.il.,�,,11..".: . , ., .1 " .. , . . . . �� I, _., 41- . 44'.- "!L�, . ; 1, . � I- " 1. ��. - . . . . I I � p . ;, , 4 � :.,,.,�,,� 1. ,.".,� I : . , . � ' , 6 . . -, , ,)l.,e,, j . �� ! " � , I , � �,. i : i . '' .:. .., .: �' L i , .., i, l . , , I I - 1, � : . . . : . . I I i � � . ,4 . I . :" " 1 I . . . I . " "', I . . IP % �� , . .. I .., __ o MO>Wwmc o m o R O �r r am FcI c z z m 0 m > ma M Oci cl ElC D � x Q m G m O O o � m a � v�� m n off f R!LlL ; 1 , CLIF 73l„µ tl.,a>k'.G" aM r� t �:� �.-a S•>.. Its 1 �ro��! , `y --�'�.�. _ � _. � ,� 1- -1 x' ; �, ""c'.�l'.w�•s}�=`�.rh'k°`nl ',�a r+1�°.s" !+ s :. - ° a �. �i �f' �1�.t M7,,Wv- OVk> E "e ��:�. �' ��+. rem � !. ._ M��t� atS�,l�ri-L`� .. �•'t- . - ,: �t 4j. , kr1'11G. � 1ttlfCt E�'f ,Swp- r u .{���� ey� K—Cf'11tJH �. vi Al,-(� Pr W i Gtrofa� { grAla :.����tIE�}tt;�:. .4.41. !I,-1r�o�.r,.t; �`� ��, � '�1.•�� ��.. - 1 �t r F �Ff r.:u- t►l azo 2�3 tt .- f .$.� ,may 1 '� J 1.� •• t � I il/ 7-7 { MiT PIJ v� y"` rt 3 a .x411 7j 1 � c :• t 7 1, y��t11Y�� 41 , �• QS • {; s J � 11 � , , n off f R!LlL ; 1 , CLIF 73l„µ tl.,a>k'.G" aM r� t �:� �.-a S•>.. Its 1 �ro��! , `y --�'�.�. _ � _. � ,� 1- -1 x' ; �, ""c'.�l'.w�•s}�=`�.rh'k°`nl ',�a r+1�°.s" !+ s :. - ° a �. �i �f' �1�.t M7,,Wv- OVk> E "e ��:�. �' ��+. rem � !. ._ M��t� atS�,l�ri-L`� .. �•'t- . - ,: �t 4j. , kr1'11G. � 1ttlfCt E�'f ,Swp- r u .{���� ey� K—Cf'11tJH �. vi Al,-(� Pr W i Gtrofa� { grAla :.����tIE�}tt;�:. .4.41. !I,-1r�o�.r,.t; �`� ��, � '�1.•�� ��.. - 1 �t r F �Ff r.:u- t►l azo 2�3 tt .- f .$.� ,may 1 '� J 1.� •• t � I il/ 7-7 { MiT PIJ 0 Q -ape) F L_ j Aj _)l 4 ti ty I 'Y' icy Ift.z. �r � R"1 ��f 6� X ��i rA >• � y � I SY' IPg h e f: 'i ., x : it•� ! M!. ;� d' 1 }C Iq1'; Si�.: r p�•yP Pt,P � '' s �� >•1 Y d rc � N,r -rtTy��wc t % .:tr1ti 1 t i� ll I r�l,dr xnLI.'� "ju}rf kh�� tsf t ,_ �fp , `A t •qi rrt :C'.Ir '� Y�.. r� ii r Irk 4 lr scii } Y� +', 1 + �, ' rl fit _ T f� . I ire «al da I 1 1 '�� ? d� �1 S>: d � 'y3 w. +g�� � lrr. A' fl, y, A " 1 i - � .• _. rt P ye° J�; 4-y pM f J A 1 P 1 j d I L n 4I.A4, .. - .._... _ .. ` ._-_..,.._ :.•.F Lr�� _. LSI � _ .— ...,. .__. .• i r ot1 31 -�5,, .511 ,41r �1 y E1 ' ('5v4 IF PL J awl 1 0 I — JR . N a <) I I � ' a r — — 1 r i _1-;Irvi N-4 adc7- cl-a ->V57 'i 0-i , (g tj V7 0) %4D _1-;Irvi N-4 adc7- cl-a ->V57 'i 0-i , (g FORM U --LOT-'RELEASE 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 or requirements. *************APPLICANT FILLS OUT THIS SECTION �i APPLICANT Po6-4 �( 5/� 23e SS z N PHONE 91r?8 738g — Eg O� LOCATION: Assessor's Map Number X PARCEL _ SUBDIVISION LOT (S) STREET (3ST. NUMBER ©� ( ** k t*** ** ****** *************O F F i C IA L U S c ONLY * * ***** ***** ** RECOMMENDATIONS OF TOWN AGENTS: (car% CONSERVATION ADMINISTRATOR.::.;::: DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED FOOD INSPECTOR -HEALTH - DATE APPROVED DATE R E �C SEPTIC INSPECTOR -HEALTH DATE -APPROVED DATE. REJECTED COMMENTS PUBLIC WORKS - SEWER/WATER CONNECTIONS DRIVEWAY PERMIT I FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm DATE i FORM!U'- LOT=- RELEASE- 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 or requirements. RECOMMENDATIONS OF -TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED I i Gtr - DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED A FOOD INSPECTOR -HEALTH - DATE APPROVED - DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTSC--G PUBLIC WORKS - SEWER/WATER CONNECTION DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm DATE *****************************APPLICANT FILLS OUT THIS SECTION***************** APPLICANT p vCg_4 / , S4 Be SS C N _ _ PHONE Of Q8 —399 Eg Ork LOCATION: Assessor's Map Number PARCEL SUBDIVISION LOT (S) STREET (?A_V eS tG ��- ST. NUMBER © � ***********************OFFlClAL USE ONLY*****************tt*** RECOMMENDATIONS OF -TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED I i Gtr - DATE REJECTED COMMENTS TOWN PLANNER COMMENTS DATE APPROVED DATE REJECTED A FOOD INSPECTOR -HEALTH - DATE APPROVED - DATE REJECTED SEPTIC INSPECTOR -HEALTH DATE APPROVED DATE REJECTED COMMENTSC--G PUBLIC WORKS - SEWER/WATER CONNECTION DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR Revised 9197 jm DATE I/ w ARGEO PAUL CELLUCCI Governor Septic Compliance, Inc F Paul Cardone, Soil Evaluator COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVi,ONMENTAL AFFAIRS. DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5600 TRUDY CORE Secretary DAVID B. STRUHS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner PART A Q / %� r=Dl CATION 7 Propert3':Address:,, Vi �•vv/ /1c.lC ✓0ZJ y�1 /Yo �iV ry 1��y1ji Namt of Owner. �� / t` %/r"T Date of Inspection: �,�x� Address of Owner./Ci��✓OL/_ J�/C�rJ/`/O �''� ov Name .ofinspecior. 'lease Print) UL C4�3 p 4 I am.a DEP ap roved system inspector pursuant to Section 15-340 of Title 5{310 CalIIt 15.000) Company Name>S �%/ C C lO�i get i� L Mailing Address: Telephone Number-. 8 % QD CERTIFICATION STATEMENT I certify that I have personally msQected the sewage disposal system at this a and complete as of the time of ddress and mat the information reported below is true„accurate iuspeciion. The. inspection was performed based on my training. and maintenance of on-site selvage disposal systems. The system: experience in the proper function and Passes A Conditionally Passes NeedsYurtherEv byt I,ocalApprovi ngAuthorityFaits Inspector's Signator Date: I ZThe System Inspector shall submit a copy of this completing this inspection if the mspechon report to the Approving Authority (Board of Health or DEP) within thirty.(30) days of shall submit the report.to thea a shared syr or hasa design flow of 10,000 gpd or greater, the inspector. and the system owner System owner. and copies sent �e b yer,iifapplicable, and the aonal 011ice of the pproving ofEn authority. Environmental Protection. The.original should be sent to the. // PPre�ng authority. NOTES AND OMMENTS c% C 7�h XYZ 4 S �J 4 J' z—a v' �/ �' l . S C-�✓/G �,� c�s—ei/y/ �,7 cy �� SCS i/` J/ �rd�% oK� / C oi�/� �/ �z�c�v�,�.� .��Gv•-�< C � ZIL•TITLE 5 SYSTEM INSPECTORST� D -E -P. SOIL EVALUATORS . 447 Boston St., Topsfield, IMSA 01983 Tel (978) 887-8586 Fax (978) 887-3480 37 % Baremeadow St., Methuen, MA 01844 Revised 92/98 Page I of I1 (978) 681-M6 !t}enat3 pasoao.zd 7vul3 Ming-sy �, �r�_s- 3 a � �— ��- ,�� �� . sno xu?s HI 'VVI asnox Twhala pasoacad rivai3 sZins-sit 18/08 '991 11:42 FAX 9784750413 J W WATSON INC I .. i i f i APPLICATION FOR DISPOSAL WORKS CONSTRUCTION PERMIT i I' DATE: r 2'19 f CURRENT INSTALLER'S LICENSJE# Y6 9 LOCATION; I Ci n d- LEs t e.1 < LICENSED SIGMA 'Soo 97,`�?S-326 ;-, CBECK per:' REPAIR_ i� NEW CONSTRUCTION: IF NEw CON 31 UCTION, PLEASE ATTACH FOUNDATION AS-BUMT. y i • k� Administm ve Use r a $75.00 Fee Attached? Yes—Az Foundation As -Built? Yes Floor Plans? I Yes Approval lig fJ 002 7, 1 TCiN,�l-C3F 51nRTH ANDOlF�R/ `� C':4RD Ct.�� taEALTH AUG 18 1999 18/08 '99 11:42 FAX 9784750410 J W WATSON INC i A�P f PLICATION FOR DISPOSAL 'WORKS CONSTRIICTION PERMU i DAZE: r CURRENT INSTALLER'S LICENSE-, 116 9 i LOCATION: S� �F! LES rr G ID d LICENSED iN.T,FRD S(�!7p s SIGNA TELEPHONE# 9 � - 7,5 2 6 REPAIIZ �C NX VV CONSTRUCTION: IF NEW CON 31 PLEASE ATTACH FOUNDATION AS -BUILT. Administrative Use Only $75.00 Fee Attar hed? yes—Az No Foundation As -Built? Yes� No_ i Floor Plans? Yes No Approval I Date.-'f//' ate: G ' OFNORTH A!`iEiO�,I , F3i Bomb 0c �EALTM AUG 181999 0 002 NORT1y O�tt�a° as 1ti O0 H m # "s • o Applic� Site Loi Permissi( bait an Individual Soil Absorption Sewage C val S.S. No. ----- CHAIRMAN, BOARD OF HEALTH Fee �5 "' D.W.C. No. Town of North Andover, Massachusetts BOARD OF HEALTH Form No. 3 -J'// F 19ya UCTION PERMIT i TELEPHONE N0RT#1 oft.._•° tle�1b oL F �A 11,E+O��no 0-t SSACHUSE Applicant Site Locat Town of North Andover, Massachusetts BOARD OF HEALTH 19 Y2 DISPOSAL WORKS CONSTRUCTION PERMIT Form No. 3 Permission is hereby granted to Construct ( ) or Repair Individual Soil Absorption Sewage Disposal System as shown on the Design Approval S.S. No. CHAIRMAN, BOARD OF HEALTH Fee �,j -- D.W.C. No. ���� Subsurface Disposal System Construction Inspection Availability Monday 9:45 — 12:00 PM Tuesday 10:45 — 12:00 PM Wednesday 9:45 — 12:00 PM Thursday 2:00 — 3:00 PM Friday 9:45 —12:00 PM All requests for septic inspections that are made before 9:30 AM, (schedules permitting) will be inspected on that day. All requests made after 9:30 AM will be inspected the following day at the available time as noted above. Please call the (978) 688-9540 for the required inspections listed below Bottom of Bed Please have the entire bed bottom exposed as per plan and a sample of the septic sand on site for observation. Final Please have all of the system pipes bedded properly and the top of the pipes exposed for review, the d -box outlets flowing level, and all the pipe connections sealed properly. The pea stone may be covering parts of the system, but do not fully spread it out. For a pump system, please fill the tank with water and have access to the building to observe electrical connections. Final Grade Please have all of the system components covered, loomed and the finish grade completed per plan specifications. Please note that the licensed installer must be readily available to supervise the ongoing construction of the system and an approved plan stamped by the town must be on site at all times. Fines may be levied for premature requests for any inspection that result in additional visits to the site by the inspector. A C Q r� V �J L r 0 W a) ZaE .v ro in V 0 Q. L a L 42 W °sA a� O E C W = p rd f� i c a� u i= v C a � !r � O V O O C r V •0 C O V O M ICN Commonwealth of Massachusetts City/Town of RECEIVE �System Pumping Record LOF o 9 2008 p` Form 4 TOWORTH ANDOVER EP T F_NTDEP has provided this form for use by local Boards of Health. Other fo � t 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 Important: When filling out 1. Syst9m Location: forms on the L� ' '� ✓ C' computer, use only the tab key Addressj �_ Q / �( �` to move your I CMZ_ V cursor - do not City/Town State Zip Code use the return key. 2. System Owner: rab Name Address (if different from location) Citylrown Stated �(—ZD od Telephone Number B. Pumping Record �, 4�_ 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes ice" No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition f System: v-, 4z---�k 6. Syst P m f3iy:�� ��a ( . Name I Vehicle License Number Company 7. Location contents were L�11 151, of 92-v� --`3 Date t5form4.doc> 06/03 System Pumping Record ^ Page 1 of 1 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. System Locatio . L Rig nt of hou eft / Right rear of house, Left/ right side of house, Left/ Right side of buil Ia ng, Left / Right front of building, Left / Right rear of building, Under deck Address 1%.)r City/Town State Trp Code 2. System Owner. Name - Address (if different from location) Citylrown ' State Telephone Number B. Pumping Record- . 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank❑Tight Tank 4. ❑ Other (describe): Effluent Tee Filter present?❑Yes o If yes, was it cleaned? '5. Conditiog ofsystem: 6. System Pumped By: 7. Neil Bateson Name Bateson Enter rises Inclnc Company were disposed: )well Waste M Date License Number ❑ Yes ❑ No: DEC 0 9 2013 4 TOWN OF NORTH ANDOVER HEALTH 11EPARTMENT 4 t5fom4.doc° 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts a 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. System Locatio . RighQnt of hou eft / Right rear of house, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town 2. System Owner. Name Address (if different State Trp Code Code lCN� 0f_ State Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Other (describe): Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yep No If yes, was it cleaned? ❑ Yes ❑ No; '5. Condition of Syst�rt:�� 6. System Pumped By.- Nell. y: 7. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company contents were disposed: & r-- C - — t t5fomi4.doc- 06/03 System Pumping Record • Page 1 of 1 Septic Compliance, Inc. E. Paul Cardone, Soil Evaluator December 22, 1998 North Andover Board of Health 27 Charles Street North Andover, MA 01845 Attn: Sandra Starr Re: Sanitary Ds osastem Inspection 81 Candlestick Road—!'Peter & Lisa Besen ted, Dear Ms. Starr: MOWN OF NORTH AND0 . BOARD OF HEALTH W In accordance with the Commonwealth of Massachusetts, Department of Environmental Protection, State Environmental Code (Title V), 310 CMR 15.301, paragraph 7, please find attached a "Subsurface Sewage Disposal System Inspection Form" for your records. If you have any questions regarding this report or any of its contents please do not hesitate to contact this office. We thank you, in advance, for your continued cooperation in these matters. Very truly yours, SEPTIC COMPLIANCE, INC. Paul Cardone Certified Septic Inspector Attachment PC/JMP title 5 Besenmps • TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS - 447 Boston St., Topsfield, MA 01983 371h Baremeadow St., Methuen, MA 01844 Tel (978) 887-8586 Fax (978) 887-3480 (978) 681-0726 ARGEO PAUL CELLUCCI Governor Septic .Compliance, Inc. .F. Paul Cardone, Soil Evaluator COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS•. DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary DAVID B. STRUHS Commissioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION / y PropertyAddress:,. NamtofOwner. _Z/ /j/a �iU V . Address of Owner. 8 / Cj�.i/O"�/C �`J/o Date of Inspection: of d n� 4 Name-.ofinspector.j(Please Print)?VL�R<J��IF I am.a DEP approved system inspector pursuant to Section 15.340 of Title 51310 CMR 15.000) Company Name� Pj/ C t�o .�-��p/i q✓!C ��-� L Mailing Address: /3cC; o„/ Telephone Number. C�78) tc387 �SgCo 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 fimction and maintenance of on-site sewage disposal systems. The system: Passes X Conditionally Passes Needs Further Eva by the l ocal.ApprovingAutherity Fails t� Inspector's Signature,Date: / Z The System Inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP) within thirty.(30) days of completing this inspection. If the system is a shared system or has 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 app/roving authority. NOTES AND COMMENTS /SCc i/� �L S�// ///� � S C•.���.l.G� �S�s-o�e;�/�/`q-� c� � Ss.'� �/J�/ �.�/ v,,,�/ `j�✓1d�L � �� gdd // oma / �p(-.., o/� ��-�1�� Otc�l�+c� •��w,�f� �S L-c� c-• `'-L ai fi yh�G� " 1-/CL,L Sy rte, �..; //�c�i'cl �� ujDCjvcO� to �'/eCc�✓iiacl�T� //0-7 • TITLE 5 SYSTEM INSPECTORS • D.E.P. SOIL EVALUATORS • 447 Boston St., Topsfield, MA 01983 37 %z Baremeadow St., Methuen, MA 01844 Tel (978) 887-8586 Fax (978) 887-3480 (978) 681-0726 Revised 9/2/98 Page 1 of I 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued, *roperty Address: Jwner: Z—;S/;L Date of Inspection: INSPECTION SUMMARY: Check A, B, C, or D: A. SYSTEM PASSES: —X— I have not found any information which indicates that any of the failure conditions described in 310 Ch1R 15.303 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. Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not. _ 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 complying septic tank as approved by the Board of Health. _ 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 rev = S r-4 9/2/98 Page 2 of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: 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 the public health, safety and 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 THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 feet of 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 PUBUC HEALTH AND SAFETY AND THE 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 soil absorption system and the SAS is within a Zone I of a public water supply well. 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 re%riS=—.. 9, 21 8 Pare 3ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM;NSPECTION FORM PART A CERTIFICATION (continued) Property Address: Owner: Date of Inspection: D. SYSTEM FAILS: You must indicate either "Yes" or "No" to each of the following: I have determined that one or more of the following failure conditions exist as described in 310 VAR 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 112 day flow. Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(sl. 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: 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: The system serves a facility with a design flow of 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: 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 II of a public water supply well) The owner or operator of any such system shall upgrade the system in accordance with 310 CMR 15.304;2). Please consult the local regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FO3M PART B CHECKLIST r'roperty Address: r Owner: �ryJ�r Date of Inspection: Check if the following have been done: You must indicate either "Yes' or "No" as to each of the following: Yes No 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 trormai 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. 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: Existing information. For example. 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)1 The facility owner (and occupants, if different from owner) were provided with information on the proper maintanaaca-of Subsurface Disposal Systems. rev -.sed ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM. PART C SYSTEM INFORMATION 'roperty Address: Owner: Date of Inspection: FLOW CONDITIONS RESIDENTIAL: Design flow Z40 g.p•d.'bedroom . Number of bedrooms (design): Number of bedrooms iac:uat!: Total DESIGN flow_ Number of current residents: Garbage grinder (yes or no) GS Laundry (separate systems (yes or no);�% If yes, separate inspection required Laundry system inspected (yes or no) Seasonal use. (yes or no):o Water meter readings, if available (last two year's usage (gpol: Sump Pump lyes or no);A,& Last date of occupancy: 0 - ie V COMMERCIAL/fNDUSTRIAL, Type of establishment: Design flow: apd ( Based on 15.203) Basis of design flow Grease trap present: lyes 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 Rjit�RD�-and souye of 7— System as part of inspection: (yes or no If yes, volume pumped: gallons Reason for pumping: GENERAL INFORMATION n TYPE OF SYSTEM _ Septic tank /distribution box:soil absorption system Single cesspool Overflow cesspool Privy Shared system lyes or no) (if yes, attach previous inspection records, if any) IIA Technology etc. Attach copy of up to date operation and maintenance contract Tight Tank Copy of DEP Approval Other APPROXIMATE AGE of all components, date installed (if known) and source of information: 4F� Sewage odors detected when arriving at the site: (yes or no) 16ZIQ TEVisea c/2% %= Pacrbofll SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORA! PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner: Date of Inspection: BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: _ cast iron _ 40 PVC _ other (explain! Distance from private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, etc.) SEPTIC TANK: (locate on site plan) Depth below grade -2--7— /V/– 7— / Material of construction: concrete _metal _Fiberglass _Polvethylene _other(explain) if tank is metal, list age _ Is.age confirmed by Certificate of Compiiance _ (Yes,No) . c Dimensions:/ Sludge dept Distance from top of sludge to bottom of outlet tee or baffler Z . Scum thickness:_ r Distance from top of scum to top of outlet tee or baffle:_ Distance from bottom of scum to bottom off outlet tee or baffle:_ How dimensions were determined—s<' 'omments: (recommendation for pumping, ondition of inlet and outlet tees or bafflQs. depth of li id levet in relation to outlet evidence of leakagg,�eettc.) GGA ✓J e � a 'r "C' GREASE TRAP- (locate on site pl n) 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: structural integrity, Comments: (recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity, evidence of leakage, etc.) rEJ�S?Q 9/2/9y, I1aC(7f4II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) property Address: Owner: Date of Inspection: TIGHT OR HOLDING TANK -j �Tank must be pumped prior to, or 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: gallonsiday Alarm present Alarm level: Alarm in working order: Yes _ No_ Date of previous pumping: Comments: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: Gs (locate on site plant Depth of liquid level above outlet inverto C -n Comments: (note,if levees distribution is equ PUMP CHAMBER Ar (locate on site pla of solids carryover, evidence of leakage into or out of by, etc.) Pumps 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.) re i c; -d 9/2/-Q--- Pact 8411 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: Owner:�� Date of Inspection: SOIL ABSORPTION SYSTEM (SAS): GS (locate on site plan, if possible: ex;2ation not required. location may be approximated by non -intrusive methods) If not located, explain: Type leaching pits, number:_ leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: 2o< overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of�ponding, damp soil, conditio f vegetation (locate on Number and configuration: Depth -top of liquid to inlet invert: Depth of solids layer: )epth 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;c�i (locate 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.) revls=: x,16!9 _ PaCc Quf 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'roperty Address: )wrw: Date of Inspection: SKETCH OF SEWAGE DISPOSAL SYSTEM: include ties to at least two permanent reference landmarks or benchmarks locate all wells within 100' (Locate where public water supply comes into house) r e %r _✓Ed 9 r-3- 10of11 7T' operty Address: Owner: Date of Inspection: NRCS Report na Soil Type Typical d USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate SITE EXAM Slope "'/V//AC' Surface water^/�%!r!/� Check Cellar f' Shailuw wells Estimated Depth to Groundwater _ Feet Please indicate all the methods used to determine High Groundwater Elevation: 1/ Oeibtained from Design Plans on record Observed Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions Checked with local Board of health _ Checked FEMA Maps Checked pumping records Checked local excavators, installers sed USGS Data SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Deep Describe how you established the High Groundwater Elevation. (Must bec/ompletecil l Q ! �e-(,. C-6 we-v-e--9�.� y e,4 S G/� of 11 f 'Ilk -1 �, � � � ire � � •tib 3 � �' ( ' � � { t; • • � Iz IN 1 !I � � � � �� -. ! � � � � � �'\ � ` �• \i � `�. 1 �'1 � cif � t t4(i � `� ('� "� ' T � � � �' � - J (I, � � Q � � . l C.._ �y'F �, 4 , 1 � �`•} \' \ + , r v, S 4 { '� ,gip 1f`► �! � J �`f Z t �, ,,, ins � , '�, ,` \ �t ` _ �• �\ � \ j � � � �! 11.1 I 1 I v Com) \ V ' V•J J L h 1\ , Ilk - � O V V =T 1 v OF � ii Lo m m Lo A ttV 00 t •a \ � � � � '�- �� �� ` `..'.�a • � �e G�% i'J`r� %4�%! K'%f'7�` f�c' tzar' ID -T b c� t }� \ 1 V � ` •{ems'• \` 00 t •a \ � � � � '�- �� �� ` `..'.�a • � �e G�% i'J`r� %4�%! K'%f'7�` f�c' tzar' ID -T .14 (� U 00 t •a \ � � � � '�- �� �� ` `..'.�a • � �e G�% i'J`r� %4�%! K'%f'7�` f�c' tzar' ID o ri (� f o ri I ") � m Z>1 C SOIL PROFILE & PERCOLATION TEST DATA Town/City No.&Street ��,r,C✓�'�- Lot No. Loc. /Subdiv. ✓ �' ,-, i ,-, W�cP�Plan Owner /C/ r� Investigator G,/ r Observer SOIL PROFILES-DATE- 1- E ev. 2. Elev. 3' Elev. 4. -Elev. �0 77 0 0 0 PM 3 1 4 5 6 7 8 9 4 5 M 7 M M 2 3 4 5 6 7 8 9 10i 10 i 10 i 10 i Benchmark Location Elevation Datum Percolation Tests -Date 22/7 Pit Number 1 2 3 4 S Start Saturation Soak -Mins. Start Test -Time Drop of 3" -Time Drop of 6" -Time U Mins.lst 3"Dro Mins.2nd 3"Dro Notes & Sketches on Back `� Nank C. Gelinas & Associates, -North And. �/ • . �4 lol Commonwealth of Massachusetts City/Town of EcIgIM System Pumping Record wM Form 4 NOV 15 01 11 yr wvrc n NI V DEP has provided this form for use by local Boards of Health. Ot r rV, s -fir M& R the information must be substantially the same as that provided here. a epi This fcmr, ck 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 Locatio1ginag',Left/ Rig fr ho , Left / Right rear of house, Left / right side of house, Left / Right side of bui / Right front of building, Left / Right rear of building, Under deck Address � r ��. Q Cityrrown 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe)' State B'0 -aa -/ti [ (,-7- � / — 2. Quantity Pumped Septic Tank Date Cesspool(s) Zip Code Statyv _� f Zip Code Telephone Number Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition Qf System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company F5821 Vehicle License Number 7. Lo IZ IZcontents were disposed: Lowell Waste Water (A Sign to a Haule Date t5form4.doc• 06103 System Pumping Record • Page 1 of 1 IM