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Commonwealth of Massachusetts R�:.�►- ,��f�
City/Town of No Andover
System Pumping Record i ��+'� "► 9 2014
Forza 4 i TOWN ofNORIHANDOVER
HEALTH t-ZPARTMENT
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351. °
A. Facility Information
1. Syste �tion:
Address
-No Andover _
City/Town
2. System O fh
Name
Aaaress (d different from location)
City/Town
r
Ma
State
State
Telephone Number
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping pate 2. Quantity Pumped:
allons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes No
5. Con ition ofSm:
r We OUs
6. System PuBy
!f yes, was it cleaned? ❑ Yes ❑ No
�4-L2�7
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
nature auyr
a ur e a
t5form4.doc- 03/06
Date
Date
System Pumping Record • Page 1 of 1
FORM U - LOT RELEASE FORM
INSTRUC
T
I N n This form is used to verify that all necessary approvals/permits from
Boards and ep rtments having jurisdiction have been obtained. This does not relieve
the app Ica an /or landowner from compliance with any applicable or requirements.
APPLICANT FILLS OUT THIS SECTION
n
PHONE ,. c, 0, r,-�f is r
LOCATION: Assessor's Map Number ,PARCEL
SUBDIVISION LOT (S)
STREET &I &3 wt_rkX�N �,i icrc ST. NUMBER__aL
*************OFFICIAL USE ONLY*********
RECOMMENDATIONS OF TOWN AGENTS: _
CONSERVATION ADMINISITRATOR DATE APPROVED
DATE REJECTED
COMMENTS
TOWN PLANNER DATE APPROVED
DATE REJECTED
COMMENTS
FOOD INSP TOR -HEALTH DATE APPROVED
DATE REJECTED
OR-F(EALTH
CO
DATE APPROVED /9 /9
DATE REJECTED
PUBLIC WORKS - SEWER/WATER CONNECTIONS
DRIVEWAY PERMIT
FIRE DEPARTMENT
RECEIVED BY BUILDING INSPECTOR DATE
ND L/NE /33-/,T
AMO"
WF
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3041�b of NEAL-q--1
NOTFH Au DOoE),�', I MA,
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Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Proceed®n
William F. Weld
Go"mor
Trudy Coxe
8eorete y, EDEA
David B. Struhs
Commissioner
SUBSURFACE SEWAGE DISPOSAL -SYSTEM INSPECTION FORM
PART A
CERTIFICATION
Property Address; Address of Owner:
Date of Inspection; 9 /c� 0,�9 7 (If different)
OCT 1 01995
Name of Inspector: 3, ,U �S(roon J4,• , ev;e/�J�y-Hc .
Company Name, Address and Telephone Number: V j5 ti. 04)(;.L4,4 � � �° � P �� �'' S � D 1 p vs,
:33 u q e47le ,ecf., N,,9,dodife,
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 to the proper function and
maintenance of on-site sewage disposal systems. The system:
Pl Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
_ Fails
ff
Inspector's Signature: (' Date:
The Svstem Inspector shall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection
The orici ,11 should be sen!. w the Scsiem Owner ano copie> Sent t0 the bw�,er, if appllu- I,le and the appro,:ng au'hon;,.
INSPECTION SUMMARY:
Check® B, C, or D:
A) SYSTEM PASSES:
✓ I have not found any. information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
Any failure criteria not evaluated are .indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair,
passes inspection.
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all instances. If "not determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration, or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank as
approved by the Board of Health.
(revised 8;15/95)
1
One Winter Street o Boston, Massachusetts 02108 0 FAX (617) 556.1049 • Telephone (617) 292-5500
10 Printed on Recycied Psper
SUBSURFACE. SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Dellis
Property Address. �l 4 / v
Owner:
Date of Inspection: cj I, D /5.'j,�
e] SYSTEM CONDITIONALLY PASSES (continued)
backup or breakout or high static water level observed in the distribution abq ns dd�on if broken
approval of he
Sewage
pipe(s) or due to a broken, settled or uneven distribution box. The system p
Board of Health)
broken pipe(s) are replaced
obstruction is removed
distribution box is levelled or replaced
ar due to broken or obstructed pipe(s) The system will pass
?;,p<tern required pumping mare than four times a ye
if fv uh approval of the Board of Health):
broken pipers) are replaced
obstruction is removed
C1 FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is, failing to protect the
public health, safer,' and the environment.
11 SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT
HE SYSTEM
IS NOT FUN I NCTIONING IN A MANNER
WHICH WILL PROTECT THE PUBLIC. HEALTH AND SA
FETY
Cesspool or is Within 50 feet of a surface water
T Cesspool or privy is. within 50 feet of a .bordering vegetated wetland or a salt marsh.
2) SYS TEM WILL FAIL UNLESS. THE BOARD OF HEALTH (AND PUBLIC.WATL C HEALTH AND SAFETY ANDD TERMINES THAT
�1
THE SYSTEM IS FUNCTIONING IN A MANNER.THAT PROTECT. THE PU
EN\'IRONMEIJ:
r. il• a Se C1lIC tank an{ Call dQCafpilOr'� si"'l E: n) and 1� wI111111 00 le6 to O �Ulfd�� �uiel i�IJ F'; (iillLuidr) iU
surace water suRPly supply System
is within ,
Thr. �.�!en%% h,!, a sel)llc tank and soil absoo{P`lo`t s stem and is wither, 50 feet of a privatelcwaterrsupply well,
he system h a, a septic tank and soli ab p Y
The s�s:rn len a sepi,c talk and soil absorption system and is less tharn 100 feet but 50 feet or more from a private ��atc
suppiv well, unless a well water analysis he CO�rtri bade of ammonia
nitrogennr1a and olatile rand nitrate n tr gen is equaltltotor3les tlhan 5
free from pollution from that facility and preenc
ppm.
Dj SYSTEM FAILS:
a is
I have determined that the system violates one orofof the H althoshouldgbe failure
contactedcriteria
to determine in
will^be necessary to R 15.303. The correct
for this determination is identified below. The Board
the failure,
tem component due to an overloaded or clogged SAS or cesspool.
Backup of sewage into facility or sys
the surface of the ground or surface waters due to an overloaded or clogged SAS or
Discharge or ponding of effluent to
cesspool.
z
(revised E/15/9``-)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address:
n�a�%u�fv2�,f
Owner:
Date of Inspection:
D) SYSTEM FAILS (continued):
Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool.
Liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
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.
El LARGE.SYSTEM FAILS:
1 he following criteria apply to large systems in addition to the criteria above,
The design flow of system is 10,000 gpd or greater (large System) and the system is a significant threat to public health and safety,
and the environment becai,se one or more of the following conditions exist,
the system is within 400 feet of a surface drinking water supply
the system is within 200 feet of a tributary to a surface drinking water supply
the system is located in a nitrogen sensitive area (Interim yNeilhead Protection Area (IWPA) or a mapped Zone II of a
pubic waler suppl% well:
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
it the local regional office of the Department for further information.
requirements of 314 CMR 5.00 and 6.00. Please consu
3
;revised 6/15/951
.r
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address:
Owner:
Date of Inspection:
. - . 9/.�0
Check if the following have been done
// Pumping information was requested of the owner, occupant, and Board of Health.
il None of the system components have been pumped for'at-least two weeks and the system -has been receiving normal flow rates
umes of water have not been introduced into the system recently or as pa
during that period. Large rt of this inspection.
vol
v As built plans have been obtained and examined. Note if they are not available with N/A.
X
✓ 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.
v 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 or
approximated b� non-intrucwp meth?xf
I/� ! ' i, r;�• (,;, �,r•.' �(, ( id((! v.ith inform, On on the proper -maintenance of Suh
Surface Disposal Svstem,
a
Property Address:
Owner:
Date of Inspection:
SUBSURFACE SEWAGE. DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION /
o 11fle
1/10/f'
RESIDENTIAL:
Design flow;_gallons
Number of bedrooms:
Number of current residents: 3
Garbage grinder (yes oro: 40
;Laundry connected to system (yes or no),
Seasonal use (yes or no):_&
Fater meter readings, if available:
FLOW CONDITIONS
90 9
L,W date of occupancy:
COMMERCIALANDUSTRIAL:
'Type of establishment:
Design flow: gallons/day
Grease trap -present: . (yes -or no)—
industrial Waste Holding Tank present: (yes or no)_
Non -sanitary waste discharged to the Title 5 system: (yes or no)_
1 ater meter readings,. if available:
;Last date of occupancy
OTHER: ;Describe) _—
(Last date of occupancy:
V s'
GENERAL INFORMATION
/0
PUty1PING _RECORDS and source of information: ,
%l1v ,-i1�i30 �y t moire 0a2� 3 le5rC5 i SaGC�� ou n�l��
System pumped as pan of inspection:
.3eorno)
If.yes, volomc t .r ,per / b d ga l^ns
Reason for pumping. J-41
TYPE OF SYSTEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
APPROXIMATE AGE of all components, date installed (if known) and source of information: T �S
Sewage odors detected. when arriving at the site: (yes or no) A?
'revised 8/15/951
5
5.-l�tl
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C -
SYSTEM INFORMATION (continued)
Property Address:
OwnerI9'���irS �u2a�A
Date of Inspection:
SEPTIC TANK:
(locate. on site plan)
rr
Depth below grade:—Z'
,vaterial of construction. k concrete metal ^FRP other(explain)
Dimensions:
Sludge depth: �/ „ .
Distance from top of sludge to bottom of outlet tee or baffle,
Scum thickness: D
Distance from top of scum to top of outlet tee or baffle: /0
Distance from. bottom of scum to bottom of outlet tee or baffle:
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.' %fink' l 5 Z� moon �° a 2 -°s T��� '4'ei o t
GREASE TRAP:_
(locate on site plane
Depth below grade
Material of construction. _concrete _,metal FRP—other(explain)
Dimensions:
Scum thickne"�
Distance from top of scum to top of outlet tee or baffle:
tl r r o r f
n{ctan,ra irpM hntrns.+ ,�,:,,.., ,,; i,�,t,r...^ nf . ou P. e o ha,ri. e
o^�r.enls
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakaee. etc
6
(revised 8/15/45
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
p SYSTEM. INFORMATION (continued)
Property Address: 0 . 'P�
Owner: i�
Date of Inspection: i
TIGHT OR HOLDING TANK:
locate on site plan)
Depth below grade:
Material of. construction: _concrete ,,,metal _FRP —other(explain)
Dimensions:
Capacity: gallons
Design flow. gallonsrda.,
Alarm level:
Comments:
t,c:ondit on of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX:
(locate on site plan;
Depth of liquid level above outlet inven t'"7)
Comments,
(: C%e' and d,R;r 4, r P;;. er,dence c cohd, cap \,over evidence of leakage Into pr Out of box etc 1
Vo L:y,�!?r�� r/ G��Ce4LoyliiG n -f3ok n r,-oo� oxo; yI'orti
PUMP CHAMBER: -
(locate on site plan)
Pumps in working order:(ges or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
.revised
F
SUBSURFACE SEWAGE'DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address; O ii /' �i ��r e/,,fp E) el
Owner: . I I
140 �nl 4 P/9
Date of Inspection:
SOIL ABSORPTION SYSTEM (SAS):___. r non -intrusive methods)
(locate on site plan, if possible; excavation not required, but may be approximated by
If not determined to be present, explain;
?ype
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number,length. -
leaching fields, number, dimensions:
overflowcesspool, number.
Comments: (note ondioon of soil, signs of hydraulic failure, level of ponding, condition of vegetaatic
CESSPOOLS:
(locate on site plan;
Number and configuration
Depth -top of liquid to inlet ;nverl
oepth of solids layer:
Depth. of scum layer:
Dimensions of cesspool:
Materials of construction
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:._
(locate on .site plan)
Dimensions:
Materials of construction:
Depth of sol ids;
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegeta tian,.etcJ
(revis.ed 8/15/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �%I' l�/l/lJ %(/ D,✓�C�O U� C' , �iiN
Owner:.
Date of Inspection:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
I
�5op aaN«
b nu
DEPTH TO GROUNDWATER
/
Depth to groundwater: feet
method of determination or approximation:
.revised e/25195i 9
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
1)ATE: S
SYSTEM OWNER & ADDRESS
AD . Z��dte�
DATE OF PUMPING: 5-7-0a
CESSPOOL: NO A — YES
SYSTEM LOCATION
(example: left front of house)
ink rt jnt 5d q)ni—
QUANTITY
PUMPED 1,50-Q GALLONS
SEPTIC TANK: NO YES X
NATURE OF SERVICE: ROUTINE X EMERGENCY
OBSERVATIONS:
GOOD CONDITION
HEAVY GREASE
ROOTS
EXCESSIVE SOLIDS
SOLIDS CARRYOVER
SYSTEM PUMPED BY:
COMMENTS:
CONTENTS TRANSFERRED TO:
FULL TO COVER
BAFFLES IN PLACE
LEACHFIELD RUNBACK
FLOODED
OTHER (EXPLAIN)
FORM Q SYSTE`' ptliv6'NG RE
Commonwealth of Massachusetts
0vtr Massachusetts
S Stem ,Pumnirl .record
ocaIon
ystem
JYslt
/✓1 acs
4vfipr 4
Z0 ov�-
Type. Emergency C) Routine
Yes No ❑ � Yes
❑ Septic Tan1::
Ccsspc .)I: No ❑ �Ilons
(.OG Quwiry Pumped: g
Date c Pumpine:
BO'RACZEK. Permit ..
S\'siel:. Pumped by (Company)
Contc :ts'trmsferTed to:
C,,,nt..)ls disposed at:
D`t� I_ Pumper Sienarure
Concidon�of system ocher comments:
