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Commonwealth of Massachusetts
9:,..;.
City/Town of NORTH ANDOVER MASSACHUSE-:� I
a,
System .Pumping Record
�. Form 4 OCT 12 2006
DEP has provided this form for use by local Boards of Health. The System Pumping Record mu
be submitted to the local Board of Health or other approving authority;— - - - ---
A. Facility Information
1. System Location:
oe
City/Town
-. State
2. System Owner:
Name
L.� r
Address (if different from location)
City/Town State ____----
Telephone Number
Zip Code
Zip Code
B. Pumping Record
9
K. Date of Pumping Date 0-a - 2. Quantity Pumped:
Gallons
3. pe of system: 13Cesspool(s) ptic Tank
ED Tight Tank
[I Other (describe):
4. Effluent Tee Filter present? ❑ Yes d6'� If yes, was it cleaned? ❑ Yesc�yNo
r
5, Condition of System:
6. Asyem Pumped By:
-- --.__._....__��
-67&) kj;fL&/� Vehicle License Number '—
Company
7. Location where contents were disposed:
Si ature of Mau �/
Date'_'.'`_--------------- --._..
http://www,mas§�gov/dep/water/ provals/t5forms.htm#inspect
t5form4.doc, 06/03
System Pumping Record • Page t of
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TOWN pFNb$TH ANDOVER
SYSTEM PUMPING RECORD
DATE
SYSTEM OWNER & ADDRESS SYSTEM LOCATION "` V
DATE OF PUMPINg QUANTITY'PUMPED jJ-Z
CESSPOOL NO Y£S ; SEPTIC TANK NO YES
NATURE OF SERVICE:; RQV�'TIME•' EMERGENCY
OBSERVATIONS:
GOOD CONDITION' ` . FULL TO COVER
HEAVY GREASE : BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS • FLOODED
. SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY "7 �-
COMMENTS:
goCONTENTS'TRANSFERRED TO °�`
DATE 1 -/,P-0-5
r si tM U WNER & ADDRESS
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM LOCATION
DATE OF PUMPING,�o� / 2 -"—QUANTITY PUMPED I -,e -,l
CESSPOOL NO ✓ YES SEPTIC TANK NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS:
J
CONTENTS TRANSFERRED TO
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TOWN OF NORTH ANDOVER flea
SYSTEM PUMPING RECORD
DATE � - eo .-..
by NTLM OWNER & ADDRESS
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SYSTEM LOCATION
DATE OF PUMPING ���p� �, -� QUq�TITY PUMPED /
CESSPOOL NO v YES SEPTIC TANK NO YES
NATURE OF SERVICE: RbUTINE EMERGENCY
-T—
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
COMMENTS:
CONTENTS TRANSFERRED TO
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TOWN OF NORTH ANDOVER
SYSTEM PUMPING R-ECORD'
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ROOTS
CXCESSIVE SOLIDS
SOLIDS CARRYOVER
>1 12''v1 PUMP CD BY:
C U Nl kl FNTS:
FULL TO COVER
BAFFLE'S IN PLACE
LEACHFICLD RUNBACK
FLOODED
;O�HFR (EXPLAIN)
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SYSTEM PUMPING RECORD
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TFOWN OF NORTHANDOVER
SYSTEM PUMPING RECORD
7 2003
�1 �'1'EM OWNER & ADDRESS „
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SYSTEM LOCATION —�
(example: left front of house)
U:\'I E OF PUMPING: 3 )/0--5? QUANTITY PUMPED LLU��
:. I'UUL: NO 1/ YES SEPTIC TANK: NO Y /
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GOOD CONDITION. FULL TO COVE
HEAVY CREASE 13AFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK..
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O HER (EXPLA.IN)
PUMPCU BY:
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0N.I'l:'.NTS TIZANSFCIZIZED TO:
TOWN OF NORTH 'ANDOVER
SYSTEM PUMPING UCORD
OWNER & ADDRESS
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No a/n&Qa v
SYSTEM LOCATION __._.
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U.\"I E OF PUMf'INC: Z/--69QUANTITY PUMI'C 0,\LLc»,
NO L,'� YES SEPTIC TANK: NO YES
� ATUKE OF SERVICE: ROUTINE EMERGENCY
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COOD CONDITION. FULL TO COYER
HEAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD IZUNOACK...
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER NHRR (EXPLA.IN)
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MATURE OF SERVICE: ROUTINE EMERGENCY
ffl1. FRY,:ITIONS
GOOD CONDITION, FULL TO COVCIz
HFAVY CREASE BAFFLES IN PLACE
ROOTS LEACHFIELD RUNBACK .2:__
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O�HFR (EXPLAIN)
Sl \)TLm PUMPED BY:
L U 1-I.NI ANTS:
0'- Fb.IN F Tl ANSFCIZIiED TO:
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SYSTEM PUM-PIR COR,
A.UDR11M «.. SYSTCM LOCATION
(MMI).1t: Icft from of house)
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SEPTIC TANK: N 0 Y E S
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�.ATUKE OF..S"ERYICE:ROUTINE.
EMERCEN"CY
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TOWN OF NORTH'AND,OYFR
SYSTEM PUMPINC R.ECOR'D
a1 y — z 2003
�1 D'I'EM OWNER & ADDRESS SYSTEM LOCATION
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U:\'I*C OF QUANTITY PUMPCD L500 0,\LLc»,
NO _,4 YES SEPTIC TANK: NO YES
� ATUKE OF SERVICE; ROUTINE �_ EMERCENCY
UII.>rRV.:\T10NS:
GOOD CONDITION. FULL TO COVCII
HPAVY CREASE BAFFLES IN PLACID
ROOTS LEACHFIELD RUNBACK... —�
CXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER p HFR (EXPLAIN)
>V TL'M PUMPCD BY.
�UNIkIrNTS:
ON*1'I:.N'I'S i'lzANSFCItR>rD'r0:
PHONE: 978-688-9640
FAX: 978-688-9542
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TO: From: �
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• Comments:
z
DATE:
LOCATION OF SOIL TESTS:
ADDRESS:
BOARD OF HEALTH
NORTH ANDOVER, MASS. 01845
978-688-9540
APPLICATION FOR SOIL TESTS
MAP & PARCEL:
TEL. NO.:
ENGINEER: TEL. NO.:
CERTIFIED SOIL EVALUATOR:
Intended use of land
Is This:
Repair testing
Residential Subdivision Single Family Home
In the Lake Cochichewick Watershed?
Undeveloped lot testing
Yes
THE FOLLOWING MUST BE INCLUDED WITH THIS FORM:
Commercial
1 . Proof of land ownership (Tax bill, deed, or letter from owner permitting tests)
2. Plot plan
3. Fee of $425.00 per lot for new construction. This covers the minimum two deep holes and two percolation tests
required for each disposal area. Fee of $200.00 per lot for repairs or upgrades.
GENERAL INFORMATION
1 . Only Certified Soil Evaluators may perform deep hole inspections.
2. Only Mass. Registered Sanitarians and Professional Engineers can design septic plans.
3. At least two deep holes and two percolation tests are required for each septic system disposal area.
4. Repairs require at least two deep holes and at least one percolation test, at the discretion of the BOH representative.
5. Full payment will be required for all additional tests within two weeks of testing.
6. Within 45 days of testing, a scaled plan (no smaller than 1"-100') shall be submitted to the Board of Health showing the
location of all tests (including aborted tests).
7. Within 60 days of testing soil evaluation forms shall be submitted.
Please Do Not Write Below This Line
N.A. Conservation Commission Approval:
Date Received: Check Amount: Check Date:
HP Fax K 1220xi
Last Transaction
Date Time Type
Apr 9 5:12pm Fax Sent
Identification
89783736611
Log for
NORTH ANDOVER
9786889542
Apr 09 2003 6:21pm
Dura ion Pages Result
0:53 2 OK
ri
TOWN OF NORTHANDOVER
SYSTEM PUMPING RECORD
> > J I CIYI v yync ,K'& AUUK1✓SS SYSTEM LOCATION —�.—
/'6 (ez�mple; lef► froni of,hou�r)
all
"00�" ao M 1�
U:\"I'C OF PUMPINC:
-
QUANTITY PUMPC,D—LLU��
�. ]-'- SPOOL: NO YES SEPTIC TANK: NO YESy
N ATURE OF SERVICE; ROUTINE EMERCENCY
t1li.>FRY,:TIONS;
GOOD CONDITION. FULL TO COYER
HEAVY CREASC BAFFLES IN PLACJ"
ROOTS LEACH FIELD RUNBACK...
CXCESSIYE SOLIDS FLOODED
SOLIDS CARRYOYER PHFR (EXPLA-IN)
PUMPED BY:
C u N1.N1 rNTS:
TRANSFCIMED TO:
DATE D �/
SYSTEMOWNER& ADDRESS
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
SYSTEM LOCATION
DATE OF PUMPING_ L 'v� D QUANTITY PUMPED t) L
CESSPOOL NO__ZYES SEPTIC TANK NO_. YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY
ge?
COMMENTS:
CONTENTS TRANSFERRED TO o?d
TOWN OF NORTH ANDOVER o�����
SYSTEM PUMPING RECORD, ap
DATE_ q�✓y,�---_
J x i5 1 CM V WNER & ADDRESSX, SYSTEM LOCATION
DATE OF PUMPING_,r -0 y QUANTITY PUMPED
CESSPOOL NOy YES
NATURE OF SERVICE: ROUTINE
OBSERVATIONS:
SEPTIC TANK NO YES
EMERGENCY
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN LACE
ROOTS LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CARRYOVER OTHER EXPLAIN
SYSTEM PUMPED BY4 z d
-- --- �4
COMMENTS:
CONTENTS TRANSFERRED TO