HomeMy WebLinkAboutMiscellaneous - 89 CHRISTIAN WAY 4/30/2018 (2)Important: When
filling out forms
on the computer.
use only the tab
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Commonwealth of Massachusetts
City/Town of NO Andover
ystem (Pumping Record
Form 4
jury 10 2014
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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 Healthy or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
System Location
89 Qhristain 4Uav_
Address~
No Andover
City,'Tow n
2. System Owner:
Kirk
Name
Address (if different from location)
City/Town
MA—__-- --- -
State Zip Code
State' Zip Code
Telephone Number
B. pumping Record
1. Bate of Pumping �.-�--- 2. Quantity Pumped: —
Date Gallons
3. Type of system: Cesspool(s) ,ErSeptic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe): --
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
ame 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
;!�tgna�aler pate
eivingFacility'Date
t5forcnd:' oc, 0System Pumping Record • Page 1 of 1
t (cir( v.rrOWt 04.
Al1UttL'JS �, SYSTEM LOCATION _
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Ve. �
QUANTITY PUMGD��
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NATURE. OF SERV CE, 'ROUTINE MERGENCY
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HrA`.Y:Y -RE `: �; :,IiAFFLES' IN I'I,ACI?
RU.O.TS` LEACHFIELD ItUNl3AC`x..,
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DEP hal provided this form for use by local Boards of Health.
besubmitted to the.local'Board of Health or other
approving s
>
A: Facility Information .
tmortant.
:j,,,when,filung out 1 .: System Location
,;,forms. on the
.'computer, use � .
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to move your:,
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Name
Address (If different from location)
Clty/l own
State. Zip Code
Telephone Number
`Tt6. Pumping Record ,.
,.,, r w4I yfttyl, r, r.�, rt )�y'"�Y.,�i•!
,.� 1 Date of Pumping ' Date 2. Quantlty Pumped
Type of system ❑ Cesspool(s) ts�eptic Tank
[]'•.Other (describe); .
y , ♦ . H 1G 4r.
Sys`t$fn Pumping. Record must
TOWN OF NOR?H
HEALTH DEPAR j :
Zip Code
Gallons
❑ Tight Tank
.;:: • 4,' Effluent Tea Filter present?. ❑ Yes, LrNoo
If yes, was If cleaned?
,r Condition of Systgm,
. ... .. y •� 7 4 vJ � '.T .,IOY ,r y
Sy a Pumped By:..,
S
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Vehide ucenae Number
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4' 7 Locatlon.where. contents Were disposed:
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Date
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❑Yes ❑No
System Pumping Record Page 1 of 1
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SYSTEM PUMPING R_ECOP-D "-
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. »i'OOL NO YES SEPTIC' TANK NO YES\(
,, C URE OF SERVICE: ROUTINE \N"- EMERCENCY
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GOOD CONDITION
HFAVY CREASE
ROOTS
CXCESSIVE SOLIDS
SOLIDS CARRYOVER
FULL TO COVE _
BAFFLLS IN PL.(�Cb' _
LEACHFIELD 1Z�Nl3AC.K _
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MONTHLY REPORT FOR 4CWN OF
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RAGGS, INC.
Subsurface Soil Disposal
Inspection Report
In Accordance With
Title 5 (310CMR 15.000)
-' ng you Since 1
n
P. 0. Box 1027, Concord, MA 01742
r7 (508) 369-1100 / (800) 287-5541
u FAX (508) 897-3848
RAGGS, INC., P. O. Box 1027, CONCORD, MA 01742
(508) 369-1100
OFFICIAL CERTIFICATION
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION
IN ACCORDANCE WITH TITLE 5 (310 CMR 15.000)
CERTIFICATION PREPARED FOR: Mary Anderle
ADDRESS OF PROPERTY: 89 Christian Way
N. Andover, MA 01845
DATE OF INSPECTION: April 6, 1995
RESULTS:
X This property has PASSED the criteria set
forth in 310 CMR 15.000.
This property has FAILED the criteria set
forth in 310 CMR 15.000.
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742
(508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
ADDRESS OF PROPERTY
OWNER'S NAME:
DATE OF INSPECTION
89 Christian Way
N. Andover, MA 01845
Mary Anderle
April 6, 1995
PART A
CHECKLIST
The following have been done -
1. Pumping information was requested of the owner, occupant, and Board of Health.. Yes
2. None of the system components have been pumped for at least two weeks and the system
has been receiving normal flow rates during that period. Large volumes of water have not
been introduced into the system recently or as part of this inspection: Yes
3. As -built plans have been obtained and examined: Yes
r�
4. The facility or dwelling was inspected for signs of sewage back-up: Yes
r 5. The site was inspected for signs of breakout: Yes
r�
6. All system components, excluding the SAS, have been located on the site: Yes
7. 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: Yes
8. The size and location of the SAS on the site has been determined based on existing
information or approximated by non -intrusive methods: Yes
9. The facility owner (and occupants, if different from owner) were provided with information
the proper maintenance of SSDS: Enclosed with report.
r-
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION
FLOW CONDITIONS
Residential: number of bedrooms: 4
number of current residents: 2
garbage grinder: yes
laundry connected to system: yes
seasonal use: no
Non -Residential, calculated flow:
Water meter readings: see Appendix D private well:
Last date of occupancy: occupied
GENERAL INFORMATION
Pumping records and source of information: see Appendix A; Homeowner
System pumped as part of inspection: yes Volume pumped: 1,000 gallons
Reason for pumping: Examination of the structural integrity of the tank.
Tvge of system -
Septic tank/distribution box/soil absorption system: yes
Single cesspool:
Overflow cesspool:
Privy:
Shared system:
Other:
Approximate age of all components: 5 years old
Date installed: 1990 approximately
Source of information: Realtor's Listing Sheet
Sewage odors detected when arriving at the site: no
2
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SEPTIC TANK (locate on site plan) -- see page 5
Depth below grade: 3"
Material of construction - Concrete: X Metal: FRP: Other:
Dimensions: 5'X 8'X 5'8"
Sludge depth: 0"
Distance from top of sludge to bottom of outlet tee or baffle: n/a
Scum thickness: 0"
Distance from top of scum to top of outlet tee or baffle: n/a
Distance from bottom of scum to bottom of outlet tee or baffle: n/a
Recommendation for pumping: annually
Condition of inlet and outlet tees or baffles: good
Depth of liquid level in relation to outlet invert: level
Structural integrity: good Evidence of leakage: good
Recommendation for repairs: none
DISTRIBUTION BOX (locate on site plan) -- see page 5
Depth of liquid level above outlet invert: zero
Level and distribution are equal: yes Evidence of solids carryover: none
Evidence of leakage into or out or box: none
Recommendation for repairs: none
PUMP CHAMBER (locate on site plan) -- n/a
Pumps in working order:
Condition of pump chamber:
Condition of pumps and appurtenances:
Recommendation for maintenance or repairs:
KI
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SOIL ABSORPTION SYSTEM (SAS) -- see page 5
(locate on site plan, if possible; excavation not required, but may be approximated by non-
r�
intrusive methods).
If not determined to be present, explain:
r;
Type:
Leaching pits and number:
Leaching chambers and number.
Leaching galleries and number:
Leaching trenches, number, length:
r Leaching fields, number, dimensions: one field; 5 lines; each approximately 50'
Overflow cesspool, number:
Condition of soil: good Signs of hydraulic failures: none
' Level of ponding: none Condition of vegetation: good
Recommendations for maintenance or repairs: none
r!
CESSPOOLS (locate on site plan) -- n/a
` Number and configuration:
Depth -top of liquid to inlet invert:
f_. Depth 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)
Condition of soil: Signs of hydraulic failure:
-� Level of ponding: Condition of vegetation:
Recommendations for maintenance or repairs:
PRI (locate on site plan) -- n/a
` ' Materials of construction:
Dimensions:
Depth of solids:
Condition of soil: Signs of hydraulic failure:
Level of ponding: Condition of vegetation:
Recommendations for maintenance or repairs:
2
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
SYSTEM INFORMATION continued
SKETCH OF SEWAGE DISPOSAL SYSTEM
* Include ties to at least two permanent references, landmarks or benchmarks
*Locate all wells within 100 ft.
SEE APPENDIX B
DEPTH TO GROUNDWATER: More than 5'
METHOD OF DETERMINATION OR APPROXIMATION: Hand augered a 4" hole to a depth
of approximately 5'. No groundwater was determined to be present.
5
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 0174215081369-1100
r-;
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
r FAILURE CRITERIA
Indicate yes, no, not applicable or not determined (Y, N, N/A or ND). Describe basis of
r determined in all instances. If "not determined", explain why not.
1. There is backup of sewage into facility: N
r;
2. There is evidence of discharge or ponding of effluent to the surface of the ground or
surface waters: N
3. The static liquid level in the distribution box is above outlet invert: N
4. Liquid depth in cesspool is <6 in. below invert or available is < 1/2 day flow: N/A
r�
5.
Required pumping 4 times or more in the last year: N
number of times pumped: N/A
r�
6.
Septic tank is: Metal: N Cracked: N Structurally unsound: N
Substantial infiltration: N Substantial exfiltration: N
r ;
Tank failure imminent: N
7.
Any portion of the SAS, cesspool or privy is below the high groundwater elevation: N
8.
Within 50 feet of a surface water: N
9.
Within 100 feet of a surface water supply or tributary to a surface water supply: N
10.
Within a Zone I of a public well: N
11.
Within 50 feet of a bordering vegetated wetland or salt marsh (cesspools and privies
r
only, not the SAS): N
12.
Within 50 feet of a private water supply well: N
13.
Less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis: N
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.
6
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART D
CERTIFICATION
Name of Inspector: Martin Weiss, P. E.
Company Name: Raggs, Inc.
Company Address.- P. 0. Box 1027, Concord, MA 01742
Certification Statement
certify that I have personally inspected the sewage disposal system at this address and that
the information reported is true, accurate and complete as of the time of inspection. The
r , inspection was performed and any recommendation regarding upgrade, maintenance and
repair are consistent with my training and experience in the proper function and maintenance of
on-site sewage disposal systems.
r�
Check one:
r _& I have not found any information which indicates that the system fails to adequately
protect public health or the environment as defined in 310 CMR 15.303. Any failure criteria not
evaluated are as stated in the FAILURE CRITERIA section of this form.
r,
I have determined that the system fails to protect public health and the environment as
defined in 310 CMR 15.303. The basis for this determination is provided in the FAILURE
CRITERIA section of this form.
Martin Weiss, Professional Engineer #19501
Raggs, Inc. certifies that all work performed on the aforementioned property was done in
accordance with the guidelines set forth in Title 5 (310 CMR 15.303).
Fred T. Fish, President
Raggs Septic Service, Inc. d/b/a E. A. Comeau
File No.- 95-4755/ANDERLEMAR
Copies to:
Payer of inspection
r ' Local Board of Health or its agent
r•
7
Date
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
APPENDIX A:
HISTORICAL
PUMPING RECORDS, REPAIR RECORDS
r,
8
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
89 Christian Way. N. Andover, MA 01845
Prior to inspection, system was last pumped in November, 1994.
r�
Source of information: Homeowner.
r
r-7
9
0
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
APPENDIX B:
SITE PLAN / AS BUILT PLAN
10
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186.30
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193.30
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182.97
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182.77
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182.52
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742(508)369-1100
11
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
APPENDIX C:
r!
LISTING SHEET
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12
( 7
VICYCU
r 'od aAlain bi4kt la .,. .t• M.gp7g �
'a 4?' ai 1
89 t irrktiati Way, North Ailidwcr
$ 39,900
Style: Colonial
Lot: 1.93 acres
Rooms- 9
Brdrotomt: 4
l3ethy: 2 Full, 1 lialf
(id:dyk. : car undrr
Arc 5 years
I 6 $ 3,989
r STRUCTURE: 1
Color: Blue Basement: Full, unfinished Screens: Yes
Exterior: Clapboard Laundry: 2nd floor Pool: No
Roof: Asphalt Deck: No Other bldg: No
Fireplaces: 3 Porch. Yes, Eric. Approx Sq Feet: 3120
Floors: HW & WW Storms: Yes
r : APPLIANCES/OPTIONS
Dile j `
f papOf 0
To toss yam! C .
From
Stove: 4 Burner
Microwave:
Yes
Central vacuum: Yes
Sink: Stainless
Trashmasher:
No
Security:
Yes - upgraded
Disposer: Yes
Washer:
No
Dishwasher. Yes
Dryer.
No
Refrigerator: No
Sump pump:
No
r SERVICES/UTILITIES
-' Elec. Service: 200
Cost:
Water.
Public
Heat: 1; HW
Hot water:
Sewer:
Private
Fuel: 41l
Air conditioning: Yes 2 zone
Zoning:
R1
ROOMS
r Living: 21'x 14' Master: 21'x 16' Library: 14'x 11'
Dining: 13' x 12' Bedroom2 13'x 11'
Family: 21'x 16' Bedroan3: 113,111,
Kitchen: 20' x 13' Bedrooin4: 14' x 13'
LISTING
Owner. Anderie Assessment: S 302,900
I Schools: Sargent, NA Mid/High MLS#:
Listing Agent: Gretchen Papineau Book: 3487 Page: 321
' Instruction: Call office, lockbox and alarm Condo fee:
Directions: Salem-Foster-Bridges-C.Way Fee Includes:
DESCRIPTION
Elegant 9 room executive custom Colonial in one of North Andover's most sought atter family neighborhoods.
Tasteful decor with exciting floor plan, open foyer and 3,100 square feet. Wooded lot with professional landscaping In
r cul-de-sac location. Many extras Include central air and vac, security system, ceiling fans, whirlpool tub, sun room
and more! New Annie Sargent Elementary School scheduled for fag opening. A must see In North Andover!
Offerings subject to errors. omissions, prior sale, change
. J
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7671
Post -It' Fax Note 7671
Dile j `
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To toss yam! C .
From
LTC H e1V
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
13
RAGGS. INC., P.O. BOX 1027, CONCORD, MA 01742(508)369-1100
Appendix D:
Water Usage
Documentation
14
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
15
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RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
' Appendix E:
Recommendations:
Repair, Pumping, & Maintenance
iu.
RAGGS, INC., P.O. BOX 1027, CONCORD, MA 01742 (508)369-1100
Recommendations
for
89 Christian Way, N. Andover, MA 01845
1. Pump system annually.
17
_J
.,ej
"g you Sine' 18')v
General Maintenance Recommendations
Proper maintenance of your septic system can help prevent premature failure of your
soil absorption system. Raggs, Inc. recommends the following:
DO PUMP your system ANNUALLY.
DO OPEN your D -Box every THREE TO FOUR YEARS.
DO ensure that your VENT PIPES are installed properly.
DO make sure you know where your TANK is LOCATED.
DO make sure you know where your LEACHING FIELD is LOCATED.
DO look for GREEN STRIPES over leaching field.
DO check to determine if you can smell any ODORS from field location.
DO bring your COVERS WITHIN 6" OF GRADE.
DO USE LIQUID DETERGENT.
DO USE NON-ABRASIVE HOUSEHOLD CLEANING PRODUCTS.
DO USE ENVIRONMENTALLY SAFE PRODUCTS.
DO INSTALL WATER SAVING DEVICES, where appropriate.
DO USE SMALL AMOUNTS OF BLEACH when cleaning toilets, etc.
DO AVOID having roof gutters and downspouts DRAIN ONTO the LEACHING FIELD.
RAGGS SEPTIC SERVICE, INC.
d.b.a. E.A. COMEAU SEPTIC
P.O. Box 1027 Concord, Massachusetts 01742 (800) 287-5541 (508) 369-1100 FAX(508)897-3848
r 1 e/4VYou Since 1890
General Maintenance Recommendations (con'd)
DON'T DISPOSE anything NON -BIODEGRADABLE IN TOILETS.
(i.e.: cigarettes, sanitary napkins, diapers)
DON'T wash paint brushes used in latex or oil PAINT.
DON'T allow any PAINT, THINNERS, OR ANY OTHER TOXIC OR CAUSTIC LIQUIDS
to go down sink or toilets.
DON'T allow ANY GREASE or FAT to enter system.
DON'T DISPOSE BONES, EGG SHELLS, COFFEE GROUNDS,OR FIBROUS MATERIAL,
etc. when using a garbage disposal
DON'T use powdered detergents with phosphates.
DON'T use any DRAIN CLEANERS.
r-�
DON'T use any ENZYMES.
DON'T use any GREASE DISSOLVERS.
DO NOT ADD ANY ADDITIVES TO YOUR SYSTEM FOR ANY REASON.
In the event of a clog or other plumbing problem, contact your local
plumber, rooter or pumper.
r DON'T PLANT any trees or shrubs WITHIN 10 FT. OF THE LEACHING FIELD.
DON'T ALLOW SPRINKLER SYSTEMS or other WATERING DEVICES OVER THE
LEACHING FIELD.
DON'T DRIVE any VEHICLES or place any HEAVY OBJECTS ON TOP OF THE
LEACHING FIELD.
DON'T INSTALL a swimming pool, a patio, or a driveway over the tank or leaching field.
r I DON'T CONNECT a basement sump pump to a household drain.
r RAGGS SEPTIC SERVICE, INC.
d.b.a. E.A. COMEAU SEPTIC
P.O. Box 1027 Concord, Massachusetts 01742 (800) 287-5541 (508) 369-1100 FAX (508) 897-3848
SE
AUG 6 2009
fP.he� plovlded )hlayl•o�rn lo, pro �,..
00 ,vpn;lllod Io ITP N. lllr local 8carc: c'r n ' 0 01 Boa/CI f�ORTHANDOVER
o v r n p,�ALTH OE2A ZTM51WT . ..
A. Faclllty In(orm�tlon
-tea � ,•a
Sys; --m location;
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r ,
Cq^A•n ,
• �1;81-PH
mP�118 Ra•�ord
Typo, 911 L Ca5s�ool(�J $aD!!C ren.
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on,Wnol9 oorilenla'woie dl9posoo:
a•,{.me4.9orlde^8(srle9Dr9Ye�ylblorm�.r naln9�bcl ^
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TOWN OF
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�WHUA WHOA 4A DOREssDkgsx�
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QUA N71TY Puwpcc. /3 O
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000D 00NDITIOIN
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"OL M CA JVD Y9 YVR'-
QrrfER -EXPLAIN
7-1
�, UN I'ttq I'J rA.A hdy tx eb 0 I't
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a
TOWN OF. NOR
k
DA 11 SYSTEM TmM�
SYSTEM UWNLK & ADDRESS
"o, A
IV
/ . Ab A�
[ANDova,
0 RECORD
-11313 1 r -l" LUUA'nON
NOV - 2 2004
TOWN OF NORTH AND'-,, E=R
HEALTH DEPARTN:E-,% f
40�- SIZL
UA Uh OF PLJMPIN(]:-._
_-QUANTITY KjMpRD�
Z5d
CL3SPOOL. NoI/,,,
SOPtic Tank: NO -YES -
NA 17UKE OF SERVICE: KOUTINE_.._.e�em RGENCY
UWSERVAnoisis: I
('Wt> CONDITION FULL 'P(3 LV VER
HEAVY ORF,"E 8AWLES IN PLACk
Rt ors LEACtMELD RUNBACK
EXCESSIVE SOLIDS --- ' FLOODED
SOLID CARRYOVER_ OTUER EXPLAIN
`Sy atom Na"d by
C'UMJVIENT-,�
WNVENI'S rKANSFERJMD I'o 141
1�
Ay.
System Owner
Type:
Cesspool:
Commonwealth of Massachusetts
WihninQton,Massachusetts
System Location
Emergency ❑ RoutineY.
No ❑ Yes ❑
Date of Pumping
NOV - 3 2004
TO`.% -4 OF NORTH ANDOVER I
HC-,',TH IA PAR T MENT
Septic Tank: No ❑ Yes/
Quantity Pumped L5� gallons
System Pumped by (Company) f2 cY overt- 77, Permit #
Contents transferred to:
Contents disposed at:
Date X�vy Pumper Signa ---- -
Condition of system/other comments:
t
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,11���A7�9o'n,N'P. I+A,rx''lytt
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y >. 7. dry t rx1 v•1, 1 ,.y!( �.
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y, jT• 1 j i
:,�fii ��% �•�3' f,� { � } 1r�a1r f11 •w�ly�' r. ' .�S y���7i}' •r:-,
r • WN OF NnDTU
ANDOVER
S`YST'F„1Vl PUM.p ,.
f !ti►x ia�'iYclj5 11
. r �r ' >w 14 ,yxb• s i ?;.,'.,'
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,Ri+w "v 7 <j• ;�• nit':. i'il 1F' r''{ � ,' �. ,• t. v � .• �.- , , • `'.' v _.. _ ,
LOCATION
Ieft•fMat of IMUM)
r itit> y3'Si''•i:.r, ytq ��,. `�,I�r' 1 *� +,r' � w.y r _ .. •
�i.F� �,i ti �' �'iFM•,��, Eye>�,
� ... � A,rs,�) � '. 1, : i�'Wt`� I 'r^v, a F;.,+ 1. v.. � .. . . ,. •-r r . ..
��/tQA.NTI1'Y
PUWED
'1111jj//���f',{,:;,� ;•�,;;� , `. �::• ..• ,.-1.�._... GALLONS
^V.Y IOU
is 1k Y�{ [(,Il�'�•N .:•, • ,•
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SFPIC TK•NO
YES .
4 ~I
MERG` .,....
y, a r1�, pL d ,r. �i��•' 17l:r. ?:w:, ., ... ,, , r, � .
j��AT�ONS.,�` is 4i rl,t�,' ', � ���f�I1 �' " Ij• ,►•+..•. • r �...�.. ..
r �;r+, yiL:, • • �II�II�� . G I TO COVER
1tOOTS BAFFLES IN PLACE
++fir LIACHFIEW CK.
sum
CARRYOV" FLOODED
1
OTHER
?.," ; ■�•.e,I,m LS;ATL o
4ir'd
d 1• 9 iR
alil' � r ,air .. �.,,,�,;•;`;; �d*'.:r&;�.,•.r ..,..
t 1 �• ♦ i i} r �1}.��'�,1 y, 7• 1 , t'1 .Ike f
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of
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. �r. x }s I t ♦��*� i14' 'l�i � �jA�rw l l , . , ti.� / • _.
Commonwealth of Massachu tts_
F City/Town of North Andover
a System Pumping Record p t
Form 4 'T 9 a toil
°M TOWN OF NORTH ANDOVER
DEP has provided this form for use by local Bo ' 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.
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name -� c �— Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
(\$twart's Pre-treatmett Plant, 20 So. Mill Bradford, Ma 01835
VI I 11j, -Q
ig r f Hauler Date
Signature of V4g Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
A. Facility Information
Important:
When filling out
1. System Location:
forms on the"'-Aq
i
computer, use
1
only the tab key
Ad ress
to move your
No.Andover
ma
01845
cursor - do not
use the return
City/Town
State
Zip Code
key.
2. System Owner: Ki rx
Name
Address (if different from location)
City/Town
State
Zip Code
Telephone Number
B. Pumping Record
9/q /
L
1. Date of Pumping Dae
' 2. Quantity Pumped:
LO
Gallons
3. Type of system: ❑ Cesspool(s)ptic
Tank ❑ Tight Tank
❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
Name -� c �— Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
(\$twart's Pre-treatmett Plant, 20 So. Mill Bradford, Ma 01835
VI I 11j, -Q
ig r f Hauler Date
Signature of V4g Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Commonwealth of Massachusetts
W City/Town of North Andover
System Pumping Record
Form 4
GSM
Pv'd 21 2012
- JV_
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.
IG n �jG--,/.
Ma
State
State
Telephone Number
01845
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping /o/s»- Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present?-2--Y'es ❑ No
5. Condition of System:
If yes, was it cleaned? /Yes ❑ No
6. S stem Pumped By:
1iQ
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste re -treatment Plant, 20 So. Mill Bradford, Ma 01835
_ Idf a
jSnature of HaulerDate
,,4=.-b 11,-11g
Signature of Rece ng acility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
A. Facility Information
Important: When
filling out forms
1. System Location:
on the computer,
�� Chn
use only the tab
key to move your
Address
cursor - do not
North Andover
use the return
key.
City/Town
VQ
2. System Owner: C jj
Name
retwn
Address (if different from location)
IG n �jG--,/.
Ma
State
State
Telephone Number
01845
Zip Code
Zip Code
B. Pumping Record
1. Date of Pumping /o/s»- Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present?-2--Y'es ❑ No
5. Condition of System:
If yes, was it cleaned? /Yes ❑ No
6. S stem Pumped By:
1iQ
Name Vehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Ste re -treatment Plant, 20 So. Mill Bradford, Ma 01835
_ Idf a
jSnature of HaulerDate
,,4=.-b 11,-11g
Signature of Rece ng acility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1