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HomeMy WebLinkAboutMiscellaneous - 86 FULLER ROAD 4/30/2018I N ot f Commonwealth of Massachusetts City/Town of FREIVED System Pumping Record Form 4 201RTHAND0\- t Rr ��DEP has provided this formfor use=by local Boards of Health. e ` be�lysed ut the information must be substantially the same as that provided her" lsfo're using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left ' # front of house Left /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 State Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yegs No Trp Code 7� �Zip Code `Z-1 Telephone Number — Z. Quntity Pumped Septic Tank Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of �ys�tem4'xc � A VA System Pumped By. - Nell y:Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany contents were disposed: t5form4.doc• 06/03 system Pumping Recons • Page 1 of 1 TOWN OF SYSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS V `A C� 0�1 SGS SYSTEM LOCATION (example: left front of house) v\'0j DATE OF PUMPING: '�-6 -06 QUANTITY PUMPED: CESSPOOL: NO v YES NATURE OF SERVICE: ROUTINE OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER l s� GALLONS SEPTIC TANK: NO YES EMERGENCY FULL TO COVER BAFFLES IN PLACE LEACHF'IELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: (- CONTENTS TRANSFERRED TO: G.L.S.D Lowell Waste ,90 - jq . COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTION s` V TITLE 5 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 53� F:,'L-LV_cz ;P--� cP-`n-f A j3>ofe 2 Owner's Name: C SLA U Owner's Address:. ¢� ,2 R. A) o i2T1-f 000 (Z Date of Inspection: �( '), Name of Inspector: (please print) Company Name: I= N L.,q& r'F- (L(,v (s - Mailing Address: (o D 1?=-6jFcH wbo O A) D Aj A a. Telephone Number:- 7(�3— be6-17 6$ CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant toSection 15.340 of Tide 5 (310 CMR 15.000 The system: V Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: The system inspector shall submit a copy of this inspKdUon report to the Approving Authority (Board of Health or DEP) within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Notes and Comments TUM OF OAL MAY R 12001 i ****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. ------s Page 2 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) 'ROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15/01 Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D A. System Passes: --V—/I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the "Conditional Pass" section need to be replaced or repaired The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Answer yes, no &, of determined (Y,N,ND) in the for the following statemot determined" please explain. The septic tank is metoand over 20 years old* or the septic tank ether metal or not) is structurally unsound, exhibits substantial &Rtration or exfiltration or tank failure ' unminent. System will pass inspection if the existing tank is replaced with a co lying septic tank as approv y the Board of Health. *A metal septic tank will pass in if it is structurally so d, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 y sold is available/ ND explain: Observation of sewage backup or brea ut gh static water level 'm the distribution box due to broken or obstructed pipe(s) or due to a broken, settl or uneven 'stribution box. System will pass inspection if (with approval of Board of Health): oken pipe(s) are repla obstruction is removed distribution box is leveled or laced ND explain: The syst equired pumping more than 4 times a year due to broken`c� obstructed pipe(s). The system will pass inspection ' (with approval of the Board of Health): \,. broken pipe(s) are replaced obstruction is removed ND explain: Page 3 of I 1 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ?ROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15/01 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 .g to protect public health, safety or the environment. 1. stem will pass unless Board of Health determines in accordance with 310 9AR 15.303(1)(b) that the sy m is not functioning in a manner which will protect public health, sa and the environment: ool or privy is within 50 feet of a surface water Cess or privy is within 50 feet of a bordering vegetated wetl d or a salt marsh 2. System will fail unless the B d of Health (and P lic Water Supplier, if any) determines that the system is functioning in a manner t t protects the ublic health, safety and environment: _ The system has a septic tank and 1 a orption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a s water supply. The system has a septic tank SAS an%theS S is within a Zone 1 of a public water supply. _ The system has a septic and SAS and is within 50 feet of a private water supply well. The system has a s3iftic tank and SAS and the SAS i'4, ess than 100 feet but 50 feet or more from a private water supply ell**. Method used to determine di ce **This system ses if the well water analysis, performed at a%to ed laboratory, for coliform bacteria and atile organic compounds indicates that the well pollution from that facility and the presen of ammonia nitrogen and nitrate nitrogen is equal tn 5 ppm, provided that no other failure g iteria are triggered. A copy of the analysis must be attaform. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) ?ROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15/01 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 V Liquid depth in cesspool is less than 6" below invert or available volume is less than % day flow ✓ Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped Vol, 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 coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form.] (Yes/No) The system fails. I have dctermined 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. La a Systems: To be cons red a large system the system must serve a facility with a design flow of PO ggpd to 15,000 �• You must indicate ei `yes" or `bio" to each of the following: (The following criteria ap to large systems in addition to the crit ve) yes no the system is within 400 feet o urface g water supply the system i;di, in 200 feet tributary surface drinking water supply _ the system im a nitrogen sensitive area (Int Wellhead Protection Area — IWPA) or a mapped ZonelIofc water supply well If you have answered "yes" to any question in Section E the system is consider significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of anya system considered a significant threat under Section E or failed under Section D shall upgrade the system m a dance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. Page 5 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST 'ROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15/01 Check if the following have been done. You must indicate `yes" or `oto" 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: Yes no � 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) [3 10 CMR 15.302(3)(b)] Page 6 of 11 OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C 'ROPERTY ADDRESS: 86 Fuller Rd. -'STEM INFORMATION North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15101 FLOW CONDITIONS RESIDENTIAL Number of bedrooms (design): _. Number of bedrooms (actual): `i DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms): Number of current residents: _4 Does residence have a garbage grinder (yes or no): ffo Is laundry on a separate sewage system (yes or no):,MD [if yes separate inspection required] Laundry system inspected (yes or no):-- Seasonal o):Seasonal use: (yes or no): = Water meter readings, if available (last 2 years usage (gpd)): Sump pump (yes or no):" Last date of occupancy: G v 2Rt; N r COMMERCIALJINDUSTRIAL Type of establishment: Design flow (based on 310 CMR 15.203): t;nnd Basis of design flow (seats/persons/sgf,etc.); Grease trap present (yes or no): _ Industrial waste holding tank present (yes or no): Non -sanitary waste discharged to the Title 5 system (yes or no): — Water meter readings, if available: Last date of occupancy/use: OTHER (describe): GENERAi. INFORMATION Pumping Records Source of information: —Ttr Zoo P efL. 96 Z. i ", ow n G 2 Was system pumped as part of theinspection (yes or no): AO If yes, volume pumped: gallons — How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM —),L Septic tank, distribution box, soil absorption system _ Single cesspool _ Overflow cesspool _ Privy _ Shared system (yes or no) (if yes, attach previous inspection records, if any) _ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract (to be obtained from system owner) Tight tank _ Attach a copy of the DEP approval _ Other (describe): Approximate age of all components, date installed (if known) and source of information: 16181 eE2_ C>1AJ ti, E(L ' Were sewage odors detected when arriving at the site (yes or no): Page 7 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'ROPERTY ADDRESS: 86 Fuller Rd. North Andover — OWNER Steven and Janice Slaton DATE OF INSPECTION: 5115101 BUILDING SEWER (locate on site plan) Depth below grade:n. t 2 _ Materials of construction: __V' cast iron _40 PVC _other (explain): Distance from private water supply well or suction line: -rowy Comments (on condition of joints, venting, evidence of leakage, etc.): P- PE i-oo1115 Croofl It- SEPTIC TANK: — (locate on site plan) Depth below grade: Material of construction: concrete —metal fiberglass —polyethylene —other(explain) — If tank is metal list age: — Is age confirmed by a Certificate of Compliance (yes or no): — (attach a copy of certificate) Dimensions: 156o cw A &. w m--- Sludge sSludge depth: I Distance from top of sludge to bottom of outlet tee or baffle: Scum thickness: Distance from top of scum to top of outlet tee or baffle: 81k Distance from bottom of scum to bottom of outlet tee or baffle: 10" How were dimensions determined: 11EA�-_o 9.i S-n(f K Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, efc.): GREASE TRAP:L)L-(locate on site plan) Depth below grade: — Material of construction: —concrete --Metal metal fiberglass —polyethylene —other (explain): — Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Page 8 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) 'ROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15/01 TIGHT or HOLDING TANK: t�L (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: Capacitygallons Design Flow: gallons/day Alarm present (yes or no): Alarm level: Alarm in working order (yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (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.): �V k- c Alt fLu ou D s i 2� .�'R�,v fes+At PUMP CHAMBER: NA- (locate on site plan) Pumps in working order (yes or no): Alarms in working orddr (yes or no): Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): Page 9 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C CvcTEM INFORMATION (continued) PROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15/01 SOIL ABSORPTION SYSTEM (SAS): (locate on site plan, excavation not required) If SAS not located explain why: Type leaching pits, number: _ leaching chambers, number: leaching galleries, number: leaching trenches, number, length: Teaching fields, number, dimensions: f Fi Epp i7 %toB"t,� Z.0 xy S overflow cesspool, number: innovativetalternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): CESSPOOL.$: Avn (cesspool must be pumped as part of inspectionxlocate on site plan) Number and configuration: Depth — top of liquid to inlet invest: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow (yes or no): Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): PRIVY: N A- (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Page 10 of 11. OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5115101 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Page 11 of 11 OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) PROPERTY ADDRESS: 86 Fuller Rd. North Andover OWNER Steven and Janice Slaton DATE OF INSPECTION: 5/15/01 STTE EXAM Slope ! Flo Surface water Check cellar Shallow wells .v�..� Estimated depth to groundwater -�4o feet Please indicate (check) all methods used to determine the high ground water elevation: Obtained from system design plans on record - If checked, date of design plan reviewed: —?L_ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: Checked with local excavators, installers- (attach documentation) —�— Accessed USGS database -explain: You must describe how you established the high ground water elevation: S i TF '22'DPS 0.q Qleos % S, 0 Lc 'F s"if`e� i hCG-. r. c7 r-eo..�c t ---s. P - D 20 P3 CSU i NJ 5'1",uP IN eft-zFrtLrAv 6f be10, G -,r-- e- TOWN OF M, khJP..( SYSTEM PUMPING RECORD DATE: S - -.0' 0 q SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) CG.vtSOv\ t' � ��� �Oas<. DATE OF PUMPING: " do -6 QUANTITY PUMPED: l GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES /_ NATURE OF SERVICE: ROUTINE J EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.D +/ Lowell Waste - Comoro wea h of Massachusetts assachusetts P. - System Pumping Record System Owner System Location 9-c, -F-T,) Y-ec 6`34 Date of Pumping: Quantity Pumped: 1 ---- gallons Cesspool: No 1 Yes Ll Septic Tank: No U Yes �- System Pumped by: Fdrejea 5ti:` vv 4ed License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: IT TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: (Q - D 9,- 1� 'Fc4-[trc RJ - (example: left front of house) DATE OF PUMPING: 69-4 -0,P— QUANTITY PUMPED_ GALLONS CESSPOOL: NO /YES SEPTIC TANK: NO YES -I NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER SYSTEM PUMPED BY: COMMENTS: FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) CONTENTS TRANSFERRED TO: L L -,< l ) Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. --� VQ system rumping Kecoru Form 4 DEP has provided this form for use by local Boards of Health. Other forms,r."'� information must be substantially the same as that provided ere:-Sefere ng local Board of Health to determine the form they use. The Sy em'It -Kr g Re the local Board of Health or other approving authority. A. Facility Information 1. System Location: _ I Address 8— City/Town 2. System Owner: Name (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): UU State ORTH ANU" TCNJt4 0 H DEPARTt\AEN O but the check with your ,be submitted to Zip Code State,--,)Zip7 Y ---,COO CO/C^ ode Telephone Number Date 2. Quantity Pumped Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9-90- If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: C)[0-)u d � �& 4� 6. System Pm . l - - &O I Name Vehicle License Number Company 7. Locatione contents we Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of ° System Pumping Record OCT 2 208 a. 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 Important: When filling out 1. System Location: Left front, left rear, left side of hous . Right fron , right rear, right sid of house. forms on the computer, use only the tab key Address to move your cursor - do not use the return City/Town State Zip Code key. 2. System Owner: ar�- L" y 3 CAA,,� Name Address (if different from location) City/Town Stat? t7 (4_C.)C0Z4 Code Telephone Number B. Pumping Record 1. Date of Pumping 2. Quantity Pumped: Date Gallons 3. Type of system: El Cesspool(s) Septic Tank Tight Tank Other (describe): 4. Effluent Tee Filter present? E] Yes M-Iqo-- If yes, was it cleaned? r] Yes No 5. Conditio�sim✓L.i;�/C 6. System Pumped By: Neil Bateson F 5821 Name Bateson Enterprises Inc Company 7. Location where contents were disposed: S. Lowell Waste Water of Vehicle License Number Date Ccs --7 cD8" t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts LHEALTH IVED City/Town of 5 2009 System Pumping Record RTH ANDOVER Form 4 EPARTMENT wM 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 tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health or -other approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of hou Right front of hous , Left rear of house, Right rear of house. Left rear of building. Right rear of building. Address City/Town State 2. System Owner: V v ' 0 1 Name Address (if different from location) City/Town Stab Telephone Number Zip Code B. Pumping Record ��`✓� � � � C� 1. Date of Pumping Date 2- Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Conditio of Syste�l/`-a` t�sC�-O—t 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S.D � Lowell Waste Water Signature of Hauler If yes, was it cleaned? ❑ Yes ❑ No V\— F5821 Vehicle License Number Date t5form4.doc• 06/03 System Pumping Record . Page 1 of 1 9. � 1 Tj ml rt O h TI � n v � _r O A v 0 A O � (4 O rr a o' m avv Arot O C m 0 m O rt O f�D � m C -s C .a 0 m 0 4 0 r� c 3 c� rt D 0 7 d 3 C. l l Tj ml rt O h TI I • rn r m C') 0` :348. 77 .I: w0 Ul \44k w m >z >Z o z� z< 0 < 7c 1500 GAL. m 0� Z 0 c:,— - -+ r- m N) p -� • -4 m w00 f m u,� N O 00 O n 0 .A OO ap r m l o m(D1 rr'v�� 1500 GAL. TANK zy00� D ,�. m z m G �m -iii f o w00 f z �7 N O 00 O n 0 > OO ap r _ z m �1 r r" z ., -o 0 -n U) —t • o m -Ti Q5 m K rri m z� rn cn^ 06 o _ rrte�, o/ Z = o• > im z 0 N CPA o mO x; rn = I • ? > C c so. . W x A G-uJ Q , o 9:-K '1. 0 OD e' C) 0 0—x 46 m zz v7 U) 0m I> O' 0 • m rn— wC) r 0 N �;7C Z 1 r F'' zo < o m u n•O : 3: 1 ccOo A m W OA m.��7 0A� p 0 O OD j7 rn z OD 0 l0 0, c� Z m v, m m O r r m m < C N N O I I m l o m(D1 rr'v�� m n zy00� D ,�. m z m G �m -iii f o w00 f �7 N O 00 n 0 > OO ap r rnD z �1 r r" z ., -o �_ ? U) —t >� m -Ti Q5 m K rri z rn (f)3 V) rrte�, O a () cn Z = 1� N CPA o mO x; = CC) ? > C c Q , o ;o 0 OD e' C) 0 3 v7 U) • V (10 �z w b� Li If) �� �c Q CO ` a © "' =WO J �✓'�l ¢ W �� v/ dao E QU Z ? V U) Y O Q Z 00 o N .1 < W Elf LU ca � r o w < 00 `J < (f) CLAJ { C� w a o ©a. C S U, 0 N UJ W J J W til I w J Z � � to Z W LL � d W 0 a L W ~' N Y owo >_ = VJ w ,^ ZI W < V W E- O I ,. 0 OT 1� Fv J Board North Y !alth aver, Mas a SUBSURFACE DISPOSAL DESIGN CHECK LIST LOT LPPROVED DATE DISAPPROVED DATE / 'rovideds Reasons: to 'i FAIL OE _ ;ag 2.5 The submitted plan must show as a minimums f a) the lot to be served-area,dimensions lot #,abutters Teflocation and log deep observation holes -distance to ties location and results percolation tests -distance to ties design calculations & calculations showing required leaching area location and dimensions of system -including reserve area existing and proposed contours g) location any wet areas within loot of sewage disposal system or ' disclaimer -check wetlands mapping (h) surface and subsurface drains within loot of sewage disposal system or disclaimer location any drainage easements within 3.001 of sesa.ge disposal system or disclaimer -Planning Board files (j) known sources of water supply within 2001 of sewage disposal system or disclaimer k),._I ation of aY proposed well to serve lot -1001 from leaching facility 'location of water lines on property -101 from leaching facility m) location of benchmark driveways ,?o garbage disposals no PVC to be used in construction (q) profile of system -elevations of basement, plumb, pipe, septic tank, distribution box inlets and outlets, distribution field piping and Other elevations (r) ma roam ground water elevation in area sewage disposal system /(s) plan roust be prepared by a Professional Engineer or other professional authorized by law to prepare such plans Reg 6 Septic Tanks (a) capac t es- % of flow, water table, tees, depth of tees, access, pumping (b) cleanout / (c) 10, from cellar gall or inground swimming pool (d) 251 from subsurface drains eg 10.2. Distribution Boxes (a) s ope greater than 0.08 eg 10.1 ) sump J ` 3ubsurfce Resign Check List FAIL I M A Leaching Pits Leaching pits ar /preferred' 'where the installation is possible ,a) calculations f leaching area -minimum 500 eq ft ,b) epacing ;c) surface a 2% d)) cover erial `e 2�� splash pad f tee elbow g no ends in pipe from d -box to pipe leaching Fields no greater an 20 minutes/inch b area -tai rsi zcr n 900 sq ft construction of field surface drainage 2 % e) 20t from cellar wall or inground s'winn ng pool L eachin enc - a calculations eaching area-rdn 500 eq ft b spacing -4 f grin 6 ft with reserve bet'ween c dimensions d) constrac on e) stone f surfa drainage 2% slope y x = Tto be shown y/x a 150 - (to be shown app val s d -by power . Board of Health BEPTIC SISTEK North Anc verzMaas. INSTALLATICK CE[MK LIST LOT U 1. Distance Tos- a. Wetlands b. Drains c. Well 2. Water Line Location 3• No PPC Pipe 4. Septic Tank - a. _Tess -_Length do To Clean Out Covers b. Cement Pipe to Tank -- on Both Sides of Tank 5. Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow b. � Leach Field or Trench a. Dimensions b. Stone Depth c. CappedEads d. Clean D=ble' Washed Stone' 7. Leach Pit a. Di en one b. Ston Depth c. Spl sh Pads d. T s e. t Pipe to Pit - Both Sides j f. lean DoubYe Washed Stone S. No Garbage Disposal 9. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted. a. Lot Location b. Dimensions of System c. Location -Ath Regar&to Pere Test d. Elevations e: Water Table ConZnwe th oCMassacliusetts '�MassacltuseUs System Pumping Record System Owner I.- Date of Pumping: L( -- �-79 Cesspool: No 14- Yes H System Location �QA T, Quantity Pumped: 4�gallons Septic Tank: No LI Yes System Pumped by: a re'doa glia ,44iQed License # Contents transferrred to : Greater Lawrence Sanitary District Date: Inspector: TCWN OF N-0RTH AMq-V ' BOARD OF HEAJH 2 " Commonwealth of Massachusetts Massachusetts system Pumping Record System Owner (6t,4v\ Date of Pumping:. C T& Cesspool: No - Yes U TOWS; Oe �� `�1T-, .f30VEF�/ frH L " . L 5 1995 System Location Oro �a,r PA N - Quatrtity Pumped: l gallons Septic Wank: No d Yes L7 a System Pumped by: refad&t gei&vww License # Contents transferrred to : Greater Lawrence Sanitary District Date: __ Inspector: Commonwealth, of Massachusetts City/Town of System Pumping Record N - Form 4 Important: When filling out forms on the computer, use only the tab key ` to move your cursor - do not use the�retum key. MAY 0 1, 2007 TOO ,i . , A,vJOVER I- EA_TH I,cFr RTMENT DEP has provided this form for use by local Boards: of Health. The System Pumping Record must be submitted to the .local Board of Health or other approving authority. . A. Facility Information 1. System Locati�r� Address Cityfrown State Zip Code %.uy-w i gwn State Zip Code Telephone Number .B. Pumping Record 1. .Date. of Pumping Date 2. QuantityPumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank- ❑ Tight.Tank ❑ other(describe) ICN Commonwealth of Massachusetts W City/Town of C IIVED System Pumping Record Form 4 AUG ER NDOV DEP has provided this form for use by local Boards of Health. Other form TOWN OF NORTH ANDOVER information must be substantially the same as that provided here. Before using inis Torm, cneCK with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of rear of house, rioht rear of hoi Isk right front of holt se7 left side of house, right side of house, Left left side of building, right rear of building, under deck. CitylTown State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Sta �� Zip Code C'7 la - Telephone Number — 2. Quan 'Pumped Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes al o If yes, was it cleaned? ❑ Yes ❑ No 5. Condition System: 6. System Pumped By: Neil J. Bateson Name Bateson Enterprises Inc. Company 7. LqqaWV-where contents were disposed: G. L. S. D. Signature F5821 Vehicle License Number Date D-.— / t t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 RECEIVE® Commonwealth of Massachusetts OCT 6 2012 City/Town of TOWN OF NORTH ANDOVER System Pumping Record HEALTH DEPARTMENT Form 4 M Vey`' DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Le / Ri ht front of hous Left / 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 Cityrrown 2. System Owner. Name ��I IF III State Address (if different from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Zip Code State Zia Code Telephone Number — 2. Quantity Pumped: Septic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes Q-Iq If yes, was it cleaned? ❑ Yes ❑ No 5. ConditionO Syst c ` �-Q� ` V-�" 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locationcontents were disposed: G.L S. ;"e)r_ Lowell Waste Water t5form4.doc• 06/03 F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1