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Commonwealth of Massachusetts
City/Town of No Andover
System Pumping Record _
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
1. System Location:
Address
No Andover MA
City/Town State Zip Code
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping / 2
Date.
3. Type of system
State Zip Code
Telephone Number
Quantity Pumped
%0G6
Gallons
F Cesspool(s) ❑ Septic Tank ❑ Tight Tank Q Grease Trap
Other (describe):
4. Effluent Tee Filter present? ❑ Yes V'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of S.Ystem:
6. System Pumped By:
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
E
of
Pre-treatment Plant, 20 So. Mill B
( 11 Yat
Vehicle License Number
.;it Y
TOS A0 r .,Artii,Vq
Ma 01835
Date
Date
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RECEIVED
DEC 0 6 2005
5YST7-Nl PUMPINQ RFC,Ok1 TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
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COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
TITLE 5
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM
PART A
CERTIFICATION
Property Address: 2/0 J o q J-I-wl S/
/ A4 .e
Owner's Name:
Owner's Address:
Date of Inspection: 3- y- /1 e-1
Name of Inspector: (please print) SSM 43L'5 !/
Company Name: -A /V Uo uF,r S f ,-7--C �r
Mailing Address: [.Z- Sr +�„�,•�''�
Telephone Number: `>2 f-- 3-72 -7V'71
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 to Section 15.340 of Title 5 (310 CMR 15.000). The system:
x Passes
Conditionally Passes
Needs Further Evaluation by the Local Approving Authority
Fails
Inspector's Signature: /1"u," , to Date: 3 -2 -o s/
The system inspector shall submit a copy of this inspection 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
****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.
Title 5 Inspection Form 6/15/2000 page 1
Page 2 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 2/0 J 0 A S I-
4 4
Owner:
Date of Inspection:
Inspection Summary: Check A,B,C,D or E / ALWAYS complete all of Section D
A. System Passes:
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 or not determined (Y,N,ND) in the for the following statements. If "not determined" please
explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally
unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the
existing tank is replaced with a complying septic tank as approved by the Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance
indicating that the tank is less than 20 years old is available.
ND explain:
Observation of sewage backup or break out or high static water level in the distribution box due to broken or
obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if (with
approval of Board of Health):
broken pipes) are replaced
obstruction is removed
distribution box is leveled or replaced
ND explain:
The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will
pass inspection if (with approval of the Board of Health):
ND explain:
broken pipe(s) are replaced
obstruction is removed
2
.. Page 3 of I 1
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 9/() J yr S- O J4
Owner: 4.
Date of Inspection: -7— "—o �./
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
is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b) that the
system is not functioning in a manner which will protect public health, safety and the environment:
Cesspool or privy is within 50 feet of a surface water I
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the
system is functioning in a manner that protects the public health, safety and environment:
-The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a
surface water supply or tributary to a surface water supply.
The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply.
_ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well.
_ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a
private water supply well". Method used to determine distance
"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.
3. Other:
, Page 4 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 210 Jo G1 .gip -v S /
Owner: -S /I A4 r- 61/C
Date of Inspection: - - �- t
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
Liquid depth in cesspool is less than 6" below invert or available volume is less than V2 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 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 compomds
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 determined 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. Large Systems: lY 4 . .
To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000
gpd.
You must indicate either "yes" or "no" to each of lite following:
(The following criteria apply to large systems in addition to the criteria above)
yes no
_ _ 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 Wellhead Protection Area - IWPA) or a mapped
Zone. II of a public water supply well
If you have answered "yes" to any question in Section E the system is considered a significant threat, or answered
"yes" in Section D above the large system has failed. The owner or operator of any large system considered a
significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR
15.304. The system owner should contact the appropriate regional office of the Department.
4
,, Page 5 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 9/0 J o /1 c 1 S 0 j t S/
Owner: 54 til ,t" 14 U I
Date of Inspection: 3 _'i .�
Check if the following have been done. You must indicate "yes" or "no" 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:
Y/eno ,
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)]
1. Page 6 of 11
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 910 0 JQ lj I t So M 5 r
Owner: -S Oto Fg Ui le
Date of Inspection: ?- 9-o c_l
FLOW CONDITIONS
RESIDENTIAL
Number of bedrooms (design): Number of bedrooms (actual): 7
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x # of bedrooms):
Number of current residents: r
Does residence have a garbage grinder (yes or no):
Is laundry on a separate sewage system (yes or no): // h [if yes separate inspection required]
Laundry system inspected (yes or no): _
Seasonal use: (yes or no): 9
Water meter readings, if available le (last 2 years usage (gpd)): -5L 0 F
Sump pump (yes or no): y
Last date of occupancy: 6 i 0��l
COMMERCIAL/INDUSTRIAL
Type of establishment:
Design flow (based on 310 CMR 15.203): gpd
Basis of design flow (seats/persons/sgft,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):
GENERAL INFORMATION
Pumping Records
Source of information: {J�
Was system pumped as part of the inspection (yes or no):� 5
If yes, volume pumped: 1,,r7-4 -- How was quantity pumped determined?
Reason for pumping:
TY OF SYSTEM
"' OF
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:
Were sewage odors detected when arriving at the site (yes or no): Ho
y Page 7 of I 1
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: �/ U ,1 U Gt 6 a S o M T
Owner: -'M �Z' r<.
Date of Inspection: 7-151-04
BUILDING SEWER (locate on site plan)
Depth below grade:
Materials of construction: mast iron _40 PVC _other (explain):
Distance from private water supply well or suction line:
Comments (on condition of joints, venting, evidence of leakage, etc.):
__III �/% �� o � D CU // /J / T/ u • r
SEPTIC TANK: Y(locate on site plan)
Depth below grade:
Material of construction: �ncrete _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: Z� f
Sludge depth: 5
Distance from top of sludge to bottom of outlet tee or baffle: 3 v
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: / y"
How were dimensions determined: 0 rel S 1 r
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels
as related to outlet invert, evidence of leakage, etc.):
-t- / XJY, 4 60 0 J C 6AJ4 o LTi o N
Ny
GREASE TRAP: _(locate on site plan)
Depth below grade: _
Material of construction: _concrete 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.):
7
Page 8 of I l
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 9/ U J 6,-//-/50-X4 s 1
Owner: !� A, It r Al vit
Date of Inspection: - fj - O
TIGHT or HOLDING TANK:%% /I(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:
Capacity: gallons
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: k5 (if present must be opened)(locate on site plan)
Depth of liquid level above outlet invert: —4�'') /
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.):
PUMP CHAMBER: f / locate on site plan)
Pumps in working order (yes or no):
Alarms in working order (yes or no):
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
1
Page 9 of I I
OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: q16 J01141S<.u/ S /
Owner: -C) dt"I 6Al u/�
Date of Inspection: 3 - j - n u
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:5
overflow cesspool, number:
innovative/alternative system Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,
etc.):
CESSPOOLS: H 11cesspool must be pumped as part of inspection)(locate on site plan)
Number and configuration:
Depth — top of liquid to inlet invert:
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: #(Iocate 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.):
9
Page 10 of 11
- OFFICIAL INSPECTION FORM — NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM'INFORMATION (continued)
Property Address: / j 0 !,1 l7 SD 1 4 S 1
Owner: C. kI �✓ t, �{
Date of Inspection: �- 9- p�•
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.
10
f#- C 1s'3 "
Y
Page 11 of 11
OFFICIAL INSPECTION FORM - NOT FOR VOLUNTARY ASSESSMENTS
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: / J 6 k 5,0 x/ S
Owner: 5dly 2--n r <
Date of Inspection:
SITE EXAM
Slope
Surface water N v w
Check cellar P
Shallow wells /"/ u N c•
r
Estimated depth to ground water 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: 7
--•'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:
11
SEWER
1.19 west street SERVICE
Methuen, MA 01844
(508)683-5709
vam }�6v*,UA
o c, sov, s -r,
0. WV4, �?Iavl-qo
I �;.0. k
COMMONWEALTH OF MASSACHUSETTS
EXECUTNE OFFICE OF ENVIRONMENTAL AFFAMS
DEPARTMENT OF ENVIRONMENTAL PROTECTION
ONE VMMR STREET, BOSTON MA 02108 (617) 292-5500
TRUDY COXE
Secretary
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Gaveraor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CMTIFICATION
Property Address: 910 Johnson Street Name of Owner: Ron Headrick
Address of Owner: 910 Johnson Street, North Andover, MA. 01845
Date of Inspection: 12/13/1999
Name of Inspector: Neil J. Bateson
I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: Bateson Enterprises Inc.
Mailing Address: 111 Argilla Road Andover, MA 01810
Telephone Number: ( 978 ) 475-4786
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 in the proper function and
maintenance of on-site sewage disposal systems. The system:
—X Passes
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
Fail
Inspector's Signature: Date: `1211311999
The System Inspector shall submit a cop of this inspection report to the Approving Authority (Board of Health or DEP)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 original should be sent to the
system owner and copies sent to the buyer, if applicable, and the approving authority.
NOTES AND COMMENTS
JAN 2 0
revised 9/2/98 Page I of 11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 910 Johnson Street , North Andover
Owner: Headrick
Date of Inspection: 1211311999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
_X I have not found any information which indicates that any of the failure conditions described in 310 CMR 15.303 exist. Any failure
criteria not evaluated are indicated below.
COMMENTS:
B. SYSTEM CONDITIONALLY PASSES:
One or move 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.
Indicate yes, no, or not determined (Y, N, or NO). Describe basis of determination in all instances. If "not determined", explain why not.
_ The septic tank is metal, unless the owner or operator has provided the system inspector with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years prior to the date of the inspection; or
the septic tank, whether or not metal, is 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 complying septic tank as
approved by the Board of Health.
Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed pipe(s)
or due to a broken, settled or uneven distribution box. The system will pass inspection if (with approval of the Board of
Health).
broken pipe(s) are replaced
obstruction is removed
distribution box is leveled or replaced
The system required pumping more than four times a year due to broken or obstructed pipe(s). The system will pass
inspection if (with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
revised 912198 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 12/1311999
C. FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions east which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES IN ACCORDANCE WITH 310 CMR 15.303 (1)(b) THAT
THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
Cesspool or privy is within 50 feet of surface water.
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH AND PUBLIC WATER SUPPLIER, IF ANY) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or
tributary to a surface water supply.
The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
The system has a septic tank and sal absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and sal absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water supply well, unless a well water analysis 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. Method used to determine distance (appro)(mation not valid).
3) OTHER
revised 912198 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 12/1311999
D. SYSTEM FAILS:
You must indicate either "Yes" or "No" to each of the following:
I have determined that one or more of the following failure conditions exist as described in 310 CMR 15.303. The basis for this
determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct the failure.
Yes No
Backup of sewage into facility or system component due to an 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.
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.
E. LARGE SYSTEM FAILS -
You must indicate either "Yes" or "No" to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to public
health and safety and the environment because one or more of the following conditions exist:
Yes No
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 Wellhead Protection Area @ IWPA) or a mapped Zone 11 of a public
water supply well)
The owner or operator of any such system Shall upgrade the system in accordance with 310 CMR 15.304(2). Please consult the local regional office of the
Department for further information.
revised 912198 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 12/1311999
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
_X Pumping information was provided by the owner, occupant, or Board of Health.
_X 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.
N/A_ _ As built plans have been obtained and examined. Note if they are not available with NIA.
_X The facility or dwelling was inspected for signs of sewage back-up.
X The system does not receive non -sanitary or industrial waste flow. The site was inspected for signs of breakout.
_X_ All system components, excluding the Soil Absorption System, have been located on the site.
X 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:
_X Existing information. For example, Plan at B.O.H.
_X Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable)
[I 5.302(3)(b)]
_X The facility owner (and occupants, if different from owner) were provided with information on the proper maintenance of
SubSurface Disposal Systems.
revised 912198 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Property Address: 910 Johnson Street, North Andover
Owner. Headrick
Date of Inspection: 12113111999
FLOW CONDITIONS
RESIDENTIAL:
Design flow.:_N/A — .g.p.d./bedroom.
Number of bedrooms (desgn):_N/A _ Number of bedrooms (actual-4—
Total
actual4_Total DESIGN flow N/A
Number of current residents: _4
Garbage grinder (yes or no): ---Yes--
Laundry (separate system) (yes or no):_No_ If yes, separate inspection required
Laundry system inspected (yes or no)
Seasonal use (yes or no): No
Water meter readings Dec. 97 to Dec. 99 20,800 ft' x 7.5 =156,000 Gals. / 730 Days = 213 Gals. / Day
Sump Pump (yes or no): _Yes_
Last date of occupancy: _Current,_
COM M ERCIALI I N DUSTRIA L:
Type of establishment:
Design flow: gpd( Based on 15.203)
Basis of design flow
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:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information: Pumped this year, owner
System pumped as part of inspection: (yes or no) Yes
If yes, volume pumped: _1000_gallons
Reason for pumping: inspect tank, baffles & tee.
TYPE OF SYSTEM
X 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)
I/A Technology etc. Attach copy of up to date operation and maintenance contract
Tight Tank Copy of DEP Approval
Other
APPROXIMATE AGE of all components, date installed (ff known) and source of information: Tank original, 29 years old. D -box & trenches 9 years old. Was
replaced in 8/90. Info at Board of Health.
Sewage odors detected when arriving at the site: (yes or no)—
No-
revised 9/2/98 Page 6 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 1211311999
BUILDING SEWER: X
(Locate on site plan)
Depth below grade: 18"
Material of construction: _X_ cast iron _ 40 PVC _ other (explain)
Distance from private water supply well or suction line:
Diameter :4"
Comments: 4" cast iron pipe thru foundation to septic tank. No leakage.
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 6"
Material of construction: _X concrete _metal _Fiberglass _Polyethylene _other (explain)
If tank is metal, list age _Is age confirmed by Certificate of Compliance _ (Yes/No)
Dimensions: 7'x 5'x 4' x 7.5 =1000 gallons.
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 21"
Scum thickness: 1"
Distance from top of scum to top of outlet tee or baffle. 8"
Distance from bottom of scum to bottom of outlet tee or baffle: 20"
How dimensions were determined: Subtract scum & sludge depths to tee length.
Comments: Pumped septic tank. Inlet baffle ok. Outlet baffle & tee Ok. Depth of liquid at outlet invert. No leakage. Snake outlet pipe to D -Box , pipe ok.
GREASE TRAP: None
(locate on site plan)
Depth below grade:
Material of construction: concrete _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:
revised 9/2/98 Page 7 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 1 211 311 99 9
TIGHT OR HOLDING TANK: _None (Tank must be pumped prior to, or at time of, inspection)
(locate on site plan)
Depth below grade:
Material of construction: concrete_ metal _Fiberglass Polyethylene_other(explain)
Dimensions:
Capacity:_gallons
Design flow:_gallons/day
Alarm present
Alarm level: Alarm in working order: Yes — No
Date of previous pumping:
Comments:
DISTRIBUTION BOX.:_X_
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments: D -box level & distribution equal. No evidence of leakage. Evidence of carryover, pumped D -Box to clean.
PUMP CHAMBER: _None, gravity system_
(locate on site plan)
Pumps in working order. (Yes or No)
Alarms in working order (Yes or No)
Comments:
Revised 912198 Page 8 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued))
Property Address: 910 Johnson Street, North Andover
Owner. Headrick
Date of Inspection: 1211311999
SOIL ABSORPTION SYSTEM (SAS); X
(locate on site plan, if possible; excavation not required, location may be approximated by non -intrusive methods)
If not located, explain:
Type:
leaching pits, number:
leaching chambers, number:
leaching galleries, number:
leaching trenches, number, length: 4 trenches 40' long.
leaching fields, number, dimensions:
overflow cesspool, number:
Altemative system:
Name of Technology:
Comments: Soil Ok. Vegetation ok. No sign of ponding to surface.
CESSPOOLS: None
(locate on site plan)
Number and configuration:
Depth -top of liquid to inlet invert:
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)
Comments:
PRIVY: None
(locate on site plan)
Materials of construction: Dimensions:
Depth of solids:
Comments:
revised 912198 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 1211311999
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent reference landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
•tot=13'4"
•to2=15'
•to3=16'8"
A to D -Box = 27' 8"
2"
4 "
=29'4"
revised 9/2/98 Page 10 of 11
' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 12/13/1999
NRCS Report name
Soil Type
Typical depth to groundwater
USGS Date website visited
Observation Wells checked
Groundwater depth: Shallow Moderate Deep
SITE EXAM Slope
Surface water
Check Cellar
Shallow wells
Estimated Depth to Groundwater 1 Feet below trenches
Please indicate all the methods used to determine High Groundwater Elevation:
Obtained from Design Plans on record
_X Observed Site (Abutting propertx, observation hole, basement sump)
X Determined from local conditions
—X—Checked with local Board of health
Checked FEMA Maps
Checked pumping records
Checked local excavators, installers
Used USGS Data
Describe how you established the High Groundwater Elevation. (Must be completed) Transfer elevation of wetland in rear yard to trench bottom.
revised 9/2198 Page 11 of 11
Tel: (978) 475-4786
Fax: (978) 475-5451
BATESON ENTERPRISES, INC.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 910 Johnson Street, North Andover
Owner: Headrick
Date of Inspection: 12/13/1999
My report contained herein does not constitute a guarantee of future usage and the functionality of the existing
septic system. Such report issued herewith is merely based upon my observations, and I hereby disclaim any further
operation of your current septic system.
W
Neil . Ba son
Bateson Enterprises, Inc.
. ..........
TOWN OF NORTH AN-DOVEP%
UA tl% SYSTEM PUMPINQ RECORI)
SYSTEM OW--N'I—ZRR & LAir%r%ot2tL,.
RECEIVED
FEB _0 2 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM LOCATION
DATE OF PVMFINQ:
.___Q0ANTTTY PUMPED
k:63SML: NON\
YES- SONC T&nk: NO. YES
NA SURE OF SERVICE: Kou'rINE...
ObSFIRVATIONS:
(K)OD CONDITION FULL 'M COVER
! VY OULASS BAMES IN PLACE,
KOOT3 LEACKFIF-LD RUNBACK
8XCESSIVE SOLIDS FLOODED
-SOLID CARRYOVER, 1— OTHER EXPLAIN
syltam Pwnp4d by
1:UMMENTS.
�:uN rem's rKANSFemi) ro
Im
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner
Date of Pumping:
Cesspool: No Yes
System Location
s�-
Quantity Pumped
Septic Tank: No
System Puipped by: C are-dea 5,04-t 4ida License #
Contents transferrred to : Greater Lawrence Sanitary District
Date: _ Inspector-
`Cr:�j gallons
Yes--
FOR 14 - SYSTEM PU.N PL\G RECORD
Commonwealth of Massachusetts
, Massachusetts
System Pumping Record
N'stem Owner
(�O' &'� nc�-
Date of Pumping: --`O 9--S--
Cesspool: No F -
System Pumped by. -
Contents transferred to
ystem Location
�(cD q6- GtAkSe��
/V. "C"��
Quantity Pumped: c � gallons
Yes ❑ Septic Tank: No
.L,S.0
Date __ __ Inspector
❑ Yes ®-
License #:
I Commonwealth of Massachusetts
+y ` , Massachusetts
System Pumping Record
System Owner
4, Qwu� I c' �
Date of Pumping: ��'-1 -3--qx�
Cesspool: No Yes [ ]
System Pumped by: 64&4"
System Location
Quantity Pumped: j�'gallons
Septic Tank: No [ ]
License #
Contents transferred to: Greater Lawrence Sanitary District
Date:
Inspector:
Yes [4 -----
JAN 2 0
BOARD OF HEALTH
120 MAIN STREET . TEL. 682-6483
NORTH ANDOVER, MASS. 01845 Ext. 32
February 8, 1993
Donna VanHooten
910 Johnson Street
North Andover, MA 01845
Dear Mrs. VanHooten:
The repair to your septic system in August of 1990 was
installed following state and local regulations current at that
time and was inspected accordingly.
I hope this letter meets your needs.
Sincerely,
Sandra Starr
Health Sanitarian
POW
1 APPLICATION FOR SEWAGE DISPOSAL INSTALLATION
HEALTH DEPARTMENT - NORTH ANDOVER, MASS.
z—
I hereby mak application for a permit for a sewage disposal installation at
I will install this system in ac-
cordance wit all the laws of the Commonwealth of Massachusetts and regulations of
the Board of Health of the Town of North Andover.
Further, I will construct the house sewer of bell and spigot pipe, the minimum
diameter being 4 inches, and will maintain a minimum grade of 1% until 10 feet pre-
ceding the septic tank, where the rade shall not exceed 2116. I will install a con-
crete septic tank of /d-V-1in size. A manhole (s) permitting easy cleaning
will be provided with removable cover (s) of iron or concrete within 12 inches of
the ground surface. I will provide subsurface disposal field with 4 inch perforated
or open jointed pipe and laid in a series of trenches, the bottom of which will pro-
vide a minimum of lineal (square) feet of effective absorption area.
The pipes will be laid on a 6 inch layer of washed gravel or crushed stone ranging
in size from 3/4 to 1-1/2 inches (dia.) and the pipes will be surrounded by similar
material to a height of 2 inches above the crown of the pipe. The joints of these
pipes will be protected from clogging and before filling the trench, 2 inches of
gravel or stone 1/8" to 1/4J' (dia.) will be placed over the course gravel or stone.
The disposal field will be installed at a grade of 4 to 6 inches/100 feet. No single
tile line will exceed 100 feet in length and in any case, two lines of tile will be
installed. A minimum of 6 feet will be maintained between the center lines of the
disposal field trenches and the average depth of trench shall not exceed 36 inches.
No part of the installation will be less than 100 feet from any private water supply,
25 feet from any stream, 20 feet from any dwelling or 10 feet from any property line.
I further agree not to cover any portion of this installation until approved by the
inspection officer, as provided below, and to incorporate any additional requirements
that may be attac ed to the perm't. Pot Plans must Jke submitted with application.
DATE -/C-70
A
I hereby issue the above permit for the Board of Health of the Town of North
Andover, Massachusetts.
DATE -7 �
Signa ure of Health Agent
I have inspected the uncovered system indicated above and find everything done
as described.
DATE �� 17e')
)JU)l AL� M K�� J
Signature .`o Inspecting Off cer
Percolation Test
Garbage Grinder �(°
c -1s -
f BOARD OF HEALTH ra"116" ss'
TOWN OF NORTH ANDOVER, MASS.
15�
/Oar
��h� s�
i
1. NAME � �.�C DATE sell
2. ADDRESS (/ r1 -a nni ll j�Lo LOT NO.--
3. NO. OF BEDROOMS— DEN YES_ ! NO
4. GARBAGE GRINDER YES < NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. NOTE LOCATION AND DISTANCE OF WELL FROM SEWERAGE SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH
TOWN OF NORTH ANDOVER, MASS.
T
17Z
ol
' V
rill -
a
\c
c �jin,y� h
5-74
1. NAME �r
DATE
2. ADDRESS. riwiw LOT N0. � TEL.
3. NO. OF BEDROOMS t2� DEN YES NO
4. GARBAGE GRINDER YES NO
5. SHOW DIMENSIONS OF HOUSE
6. SHOW DISTANCES OF HOUSE TO ALL PROPERTY LINES
7. SHOW DIMENSIONS OF LOT
8. SHOW LOCATION AND SIZE OF SEPTIC TANK OR CESSPOOL
9. D DISTANCE OF WELL FROM SEWERAGE"SYSTEM
10. SHOW LOCATION OF BROOKS, STREAMS, DITCHES, LEDGE OUTCROP, ETC.
11. SHOW DISTANCE OF SEPTIC TANK OR CESSPOOL FROM HOUSE
NOTE: LOCAL REGULATIONS SHOULD BE READ CAREFULLY.
BOARD OF HEALTH OF NORTH ANDOVER$ MASSACHUSETTS
SEWAGE DISPOSAL
DATE 7/j6Z7p
NAME OF APPLICANT George Farr
LOCATION 910 Johnson St. (also known as 33 Farnum)
Address of lot no.
BUILDING:
Dwelling X' Other
SYSTEM: New X Repair
GENERAL DESCRIPTION OF LAND high
SUBSOIL: Clay X Gravel Sand
PERCOLATION TEST 7 minutes per inch.
MINIMUM INSTALLATION RECOMMENDATIONS
CONCRETE SEPTIC TANK 1000 gallon capacity.
LEACH FIELD 200 lineal feet of drain pipe.
�Px,_,
William J. r scoll, Eng'neer
Board of Hea h
0-4 1 jsr-� rq--�v --
.� v 4*4
Za +- Yob 6Ln
V4\qTz-
syj
F-
LU
ro
00
H0
Q�
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Q LL
cc Q
n<
am
S
-�
eral Laws
sing Partnership
tensive Care Unit (see ALS)
erlocal Insurance Association
Information Service (ICMA); Management
,)n System (Data Processing)
LCipal Association
�cipal Management Association
-opolitan Statistical Area
'DEModulates (computer linkage)
:an Planning Organization
Valley Planning Commission
Valley Regional Transit Authority
Association for the Advancement of
ople
ver Conservation Commission
3sociation of Counties
,er Fire Department
er Housing Authority
iphalt Pavement Association; North
ie Association (union)
Police Department
ation of Regional Councils
of Standards
formation Center
Association; National Energy
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner System Location
�
....... (AAA -
41 --7
41'
Date of Pumping:
Cesspool: No�,— Yes ❑
Quantity Pumped: intgallons
Septic Tank: No ❑ Yes
System Pumped by: 644d4k 9i�8d License #
Contents transferrred to : Greater Lawrence 8arlsy p.istrict
Date: Inspector: _ .
r commonwealth of Massachusetts
/ v ; Massacliusetts
4
J�
system 1'um�in� Record
System Otwer
GL
Date of Pumping: [ C — t -?, q
Cesspool: No [- Yes U.)
V/
System Location
of 162 q9 wl. a4
Quantity Pumped:
Septic Tank: No 0 Yes
System Pumped by: Mirwelf Fo.eeyti4P,cf License #
Contents transferrred to : Greater Lawrence Sanitary distrlct
.Date: _ Impector:
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE:
SYSTEM OWNER & ADDRESS
San) ei Q'
SYSTEM LOCATION
(example: left front of hour
DATE OF PUMPING: QUANTITY PUMPED D GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES IXI
NATURE OF SERVICE: ROUTINE 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)
AINK`—
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ai : 1 (M.,YI S.i p N / t It,l , l ti � r l �'., , •, � � �"' 5Y " `�'
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be:ubmltted to the.local'Board of Health or other approvin8 aut y tem Pumping Recolc .T
A, Facility .lnforr��tlon
JaWhan f�npiout .1;:::; System Location'
meter met`,;
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Commonwealth of Massachusetts
W City/Town of North Andover
a 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
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.
1. Date of Pumping
3. Type of system:
Date
❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. tem Pumped By:
Li "
Name
Stewart's Septic Service
Company
OCT 18 ZU11
i 4 1TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Ma
State
State
Telephone Number
2. Quantity Pumped
Septic Tank ❑ Tight Tank
01845
Zip Code
Zip Code
1606
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
�St�wart's Pre-treatment Plant. 20 So. Mill Bradford, Ma 01835
Signature of Hauler'
Signature of Receiving F ity
Date
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
computer, use
Sol, -
only the tab key
Address
to move your
No.Andover
cursor - do not
City/Town
use the return
key.
2. System e '
r
Name
Address (if different from location)
City/Town
B. Pumping Record
gl�>ir
1. Date of Pumping
3. Type of system:
Date
❑ Cesspool(s)
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
6. tem Pumped By:
Li "
Name
Stewart's Septic Service
Company
OCT 18 ZU11
i 4 1TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
Ma
State
State
Telephone Number
2. Quantity Pumped
Septic Tank ❑ Tight Tank
01845
Zip Code
Zip Code
1606
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
7. Location where contents were disposed:
�St�wart's Pre-treatment Plant. 20 So. Mill Bradford, Ma 01835
Signature of Hauler'
Signature of Receiving F ity
Date
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1