HomeMy WebLinkAboutMiscellaneous - 90 CAMPBELL ROAD 4/30/2018I
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Commonwealth of Massachusetts
. City/Town of No Andover
° System Pumping Record
Form 4
'M
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
iocal 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
RECE
Important: When
filling out forms
1. System Location
on the computer,
(911-1
use only the tab
key to move your
Address
cursor - do not
No Andover
use the return
key.
City/Town
2. System Owner:
�e-/i4% Pt
rcoon
Name
Address (if different from location)
City/Town
B. Pumping Record
s
Ma
State
NOV 122013
TOWN OF NORTH ANOOV@R
State
Telephone Nun ber
Zip Code
1. Date of Pumping D t / 2. Quantity Pumped:
3. Type of system:
❑ Other (describe)
a e Gallons
❑ Cesspool(s) N Septic Tank ❑ Tight Tank ❑ Grease Trap
4. Effluent Tee Filter present? ❑ Yes ❑ No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped,§�y,
Name FVehicle License Number
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Hauler
Signature of Receiving Facility
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
Board of Health
North An4O_V_e_r_.,,M;L5B*
M=�
2_Z_
SEPTIC SYSTEH
INSrAMATICK CHECK LIST
LOT 31 c4M
EXCAVATI OK FAIL
1. Distance To:
a. 'Wetlands
b. Drains
c 0. Well
2. Water Line Location
3. No PVC Pipe
Septic Tank
a. -Tees .-Length & To Clean Out Covers
b. Cement Pipe to Tank — On Both Sides of Tank
5,,V,aDistribution Box
m. Covers & Box No Cracks
b. All Lines Flo -wing Equal Amounts
c. No Back Flow
6. Leach Field or Trench
a. Dimensions
b. Stone Depth
c: Capped Ends
d. Clean Double*Washed Stone
7. Leach Pits
a. Dimensions
b. Stone Depth
co Splash Pads
d. "Te -es
8. Cement pipe to pit Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. -Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard -to Pere Test
d. Elevations
e Water Table
Board of Health
North Andover,Mass
This I S r-01� lav (5ep sHW!��
RAO P4" 6-js-i
.SUBSURFACE DISPOSAL DESIGN CHECK LIST
LOT 3 GOMjG-
APPROM DATEJ&�l- DISAPPROVED DATE
Provideds Reasons:
�- 16fA, ML)51f4.2( 4ti0
S4440 6109 �5, (WuD' L-' CA i3CJ
Title V
Reg 2.5
p
-2
O` ---�
O�system
Reg 6
FAIL
OK
The submitted plan must show as a adnimams
a) the lot to be served -area, dimensions lot #,abutters
b location and log deep observation hoes -distance to ties
CC location and results percolation tests -distance to ties
d design calculations & calculations shoaling required leaching area
(elocation and dimensions of system -including reserve area
f existing and proposed contours
(g) location any wet areas within 1001 of sewage disposal system or
disclaimer -check wetlands mapping
surface and subsurface drains within 100+ of sewage disposal
or disclaimer
location any drainage easements within 100, of sewage disposal
system or disclaimer -planning Board files
(j)*known sources of Water supply within 2001 of serge disposal
system or disclaimer
(k) location of MY proposed well to serve lot -1001 from leaching facility
location of water lines on property -101 from leaching facility
(m) location of benchmark
(n) drive -ways
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) maximum ground water elevation in area sewage disposal system
s) plan must be prepared by a Professional Engineer or other
professional authorized by law to prepare such plans
Septic Tanks
(a) capac t es- 50,% of flow, water table, tees, depth of tees,
access, pumping
(b) cleanout
c) 101 from cellar wall or inground swimming pool
'd) 251 from subsurface drains
I,
_
�(h)
(�(i)
t/
71"(1)
C.-,
i
Reg 10.2
Reg 10.4
Distribution Boxes
slope greater than 0.08
sump
'S - I , !�.
_'N 'h,, T
Lot No
North Ando \kr, Mass,* Street No-- Pland O-V.,ner
lj,)C/S-o.bd.iv
ln�.estigator_ 0 Observer
SOIL PROFILE DATES
2.Elev 3. El ev 4.Elev
_'El ev
0 0
r) 0
2
4
5
6
9
i
Benchmark
Elevation
1
2
3
4
5
6
7
8
9
1-0
2 1__1 2
V.,
ILI
4
Ti -es to Tes
Pits
Pit Number
Start Sa-L-,U-ra'L,--*,on
2
5
5
6
6
MWA'S CPO
�/*d
of
-Drop
Drop _p_L6"-Tun e
7
7
N1fS.,s.lst 3" drop
Mil -'s 21.d
Pe-rcol;-tion
8
9
*pop'
0
1_0
Location
Datxn
P�,-_�RCOT J TION TESTS
Pit Number
Start Sa-L-,U-ra'L,--*,on
2
soak, -Minutes
tdj___C
of
-Drop
Drop _p_L6"-Tun e
N1fS.,s.lst 3" drop
Mil -'s 21.d
Pe-rcol;-tion
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