HomeMy WebLinkAboutMiscellaneous - 93 ROCKY BROOK ROAD 4/30/2018 (19)(• !
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CONSTRUCTI.ON__APPRO.,,, L
HAS PLAN REVIEW FEE BEEN PAID YE NU
PLAN APPROVAL: DATE APP. BY.
5 J PLAN Dfl I�E.
DESIGNER: G�1�1 JZ
CONDITIONS ___-: --.-_---__.---
WATER SUPPLY:
WELL PE
WELL TESTS:
COMMENTS:
WN WELL
DRILLER._..._._._._.-_......... __._....._._-..._..............._._:_.._... _....._.. .
CHEMICAL DAZE fel P RUVED......---....__ .._._ ..---.
1111 - ERIA I DA I E f1PPRUVED
BACTERIA II DAIE APPROVEll._,__..____„_
FORM U APPROVAL: APPROVAL 1*0 ISSUE YES NO
DATE ISSUED S �f �� BY
CONDITIONS:
FINAL APPROVAL:
ALL PERMITS PAID NO
WELL CONSTRUCTION APPROVAL YES NU
SEPTIC SYSTEM CONSTRUCTION APPROVAL-L��-SD NO
OTHER YES NU
ANY VARIANCE NEEDED YES NO
FINAL BOARD OF HEALTH APPROVAL: DATE:._...___..,,.,._.:._
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,THE • INSTALLER LICENSED?.,
TYPE OF- CONSTRUCTION: ?� .-NEW REPAIR'
CERTIFIED PLOT.PLAN•REVIEW ES NO
..,NEW CONSTRUCTION: NO
' �;' - CONDITIONS OF..APPROVAL
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_. YES NO
`.,ISSUANCE OF DW PERMIT _
DWC PERMIT..NO. +INSTALLER:
BEGIN INSPECTIDN YE 0: -
... -- ; :: ;. - - , .:: ': ,: - ,:..:, . --. r- .. :.... • . :NEEDED:
EXCAVATION INSPECTION: _ .
PASSED
CONSTRUCTION INSPECTION: NEEDED:
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AS BUILT PLAN SATISFACTORY: \YESs
'APPROVAL TO BACKFILL: DATE:` BY
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.'' FINAL.GRADING APPROVAL: DATE M6ABY
FINAL CONSTRUCTION APPROVAL: DATE:
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,SSACMUSES
Town of North Andover, Massachusetts
BOARD OF HEALTH
Form No. 2
,�O_ �L� .1.1 l •
DESIGN APPROVAL FOR
SOIL ABSORPTION SEWAGE DISPOSAL SYSTEM
Applicant --7 ) ���Test No.
Site Location L ( 15
Reference Plans and Specs._ 22
ENGINEER I DESIGN U I DATE
Permission is granted for an individual soil absorption sewage disposal system to be installed
in accordance with regulations of Board of Health.
Fee
CHAIRMAN, BOARD OF HEALTH
Site System Permit No. 10G
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FORK U - LOT RELEASE FORK
INSTRUCTIONS: This form is used to verify that all necessary
1 't f
approva s/perms s rom Boards and Departments having jurisdiction
have been obtained. This does not relieve the applicant and/or
;landowner from compliance with any applicable local or state law,
regulations or requirements.
****************Applicant fills out this section*****************
APPLICANT: fL_/�,� t//yS /, �;n L" A�JS Rv c/raN� Phone
LOCATION: Assessor's Map Number _ Parcel v -C
Subdivision Lot(s)
n
Street St. Number
************************Official Use Only************************
RECOMMENDATION OF WN, -AGENTS:
�l Date Approved J
Conservation Administrator Date Rejected
Comments
Date Approved
Town Planner Date Rejected
Comments
Date Approved
Food Inspector -Health Date Rejected
-'" - Date Approved J S g
.Septic nspector-Health Date Rejected
Comments
Public Works - sewer/water connections
- driveway permit
Fire Department
Received by Building Inspector Date
..- .. �:`'Lti:t`i':v:L+'ria^vY.a�i�.i:u:►.H�r.y
DATE Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE Y v PERMIT # DATE RECEIVED1ZI�
APPLICANT '�Gx,/ ASSESSOR'S MAP /D/9
ADDRESS PARCEL #
LOT # A5
91 STREET --PGX V R ALOXf IRO
Ei+GINEER
ADDRESS
PL= -'1 DATE REVISION DATE
CO:TDITIOTS OF APPROVAL: 7-1-147- -oetiG,v1v1oet' TQ oc:5
APPROVED
DISAPPROVED
TOWN OF NORTH[ ANDOVER
SYSTEM PUMPING RECO
RECEIVED
DATE:
f -�� NOV - 9 2005
TOWN OF NORTH ANDOVER
HEALTH DEPARTMENT
SYSTEM OWNER & ADDRESS SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: v Q ANTITY PUMPEDGALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
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)
Commonwealth of Massachusetts
/,/, Massachusetts
System Pumping Record
System Owner
System Location
&713
Date of Pumping: 16)" 1
Cesspool: No {-r� Yes [ ]
System Pumped by: Tat8d"
Quantity Pumped: /&�allons
Septic Tank: No [ ]
License #
Contents transferred to: Greater Lawrence Sanitary District
Date:
Inspector:
Yes [4 --
Contents
4- —
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS
DEPARTMW OF ENVMONNMAL PROTECTION
ONE MITER STREET, BOSTON MA 02108 (617) 292-5500
LWO
TRUDY CORE
Secretuy
ARGEO PAUL CELLUCCI DAVID B. STRUHS
Governor Commissioner
SUBSURFACE SEWAGE DISPOSAL SYSTEM 6ySPECTION FORM
PART A
CERTIFICATION
Property Address: 93 Rocky Brook Road, North Andover Name of Owner: Joann Cables
Address of Owner: 93 Rocky Brook, North Andover, MA 01845
Date of Inspection: 10/1/1999
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
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 .
4cop
.
Inspector's Signature: Date: 10/1/1999
The System Inspector shall ubthis inspection report to the Approving Authority (Board of Health or DEP)wiEhin 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
i
OU 12 11999
revised 9/2/98 Page I of 11
Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 93 Rocky Brook, North Andover
Owner: Cablas
Date of Inspection: 1011/1999
INSPECTION SUMMARY: Check A, B, C, or D:
A. SYSTEM PASSES:
R
_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 912/98 Page 2 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 93 Rocky Brook, North Andover
Owner: Cables
Date of Inspection: 10/1/1999
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 the
public health, safety and 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 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 soil absorption system and the SAS is within 50 feet of a private water supply well.
The system has a septic tank and soil 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 (approximation not valid).
3) OTHER
revised 9/2/98 Page 3 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: 93 Rocky Brook, North Andover
Owner: Cables
Date of Inspection: 10/1/1999
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 F 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 9/2/98 Page 4 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Address: 93 Rocky Brook, North Andover
Owner: Cablas
Date of Inspection: 10/1/1999
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.
_X 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 9/2/98 Page 5 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION P
PART C
SYSTEM INFORMATION
Property Address: 93 Rocky Brook Road, North Andover
Owner: Cables
Date of Inspection: 10/111999
FLOW CONDITIONS
RESIDENTIAL:
Design flow::_165 ..g.p.d./bedroom.
Number of bedrooms (design): 4_ Number of bedrooms (actual): -
4 -Total DESIGN flow _660_
Number of current residents:
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, if available (last two year's usage (gpd):
Sump Pump (yes or no): _No_
Last date of occupancy: _Current
COM M E RCIALI I N D USTRIA L:
Type of establishment:
Design flow: gp_d ( 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 in 97, Owner.
System pumped as part of inspection: (yes or no)_Yes_
If yes, volume pumped: _1500_gallons
Reason for pumping: Inspect tank & tees.
TYPE OF SYSTEM
_5 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 (if known) and source of information: 4 years old. Aug. 30, 1994, as built plan.
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: 93 Rocky Brook Road, North Andover
Owner. Cables
Date of Inspection: 10/1/1999
BUILDING SEWER: X
(Locate on site plan)
Depth below grade: 20"
Material of construction: _X cast iron _X_ 40 PVC _ other (explain)
Distance from private water supply well or suction line:
Diameter: 4"
Comments: 4" cast iron thru wall, 3" PVC in house.
SEPTIC TANK: X
(locate on site plan)
Depth below grade: 8"
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: 10' x 5' x 4' x 7.5 =1500 gallons
Sludge depth: 2"
Distance from top of sludge to bottom of outlet tee or baffle: 25"
Scum thickness: 2"
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: 19"
How dimensions were determined: Subtract scum & sludge depths to tee length.
Comments: Pumped septic tank. No inlet tee or baffle. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage.
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: 93 Rocky Brook Road, North Andover
Owner: Cablas
Date of Inspection: 10/1/1999
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.: rX_
(locate on site plan)
Depth of liquid level above outlet invert: 0
Comments: D -box level & distribution equal, has flow levelers in all lines. No 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 FORI
PART C
SYSTEM INFORMATION (continued))
Property Address: 93 Rocky Brook Road, North Andover
Owner: Cables
Date of Inspection: 10/1/1999
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: 3 trenches 46' long.
leaching fields, number, dimensions:
overflow cesspool, number:
Alternative 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 9/2/98 Page 9 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: 93 Rocky Brook Road, North Andover
Owner: Cables
Date of Inspection: 10/1/1999
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)
Ato 1 =28'
Ato2=29'5"
A to D -box = 35'6"
B to 1 = 50'3"
Bto2=44'2"
B to D -box = 48'2"
revised 9/2/98 Page 10 of 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORI
PART C
SYSTEM INFORMATION (continued)
Property Address: 93 Rocky Brook Road, North Andover
Owner: Cablas
Date of Inspection: 10/1/1999
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 6 Feet
Please indicate all the methods used to determine High Groundwater Elevation:
_X Obtained from Design Plans on record
_X Observed Site (Abutting property, observation hole, basement sump etc.)
_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. As per design plan.
revised 912/98 Page 11 of 11
d
I ATENUN ENTEltl FJSES, INC;.
Excavating -Water.& Sewer Lines -Septic Systems & Pumping Service
111 Argilla Road Andover, Mass. 01810
Title 5 Inspection Report
Property Address: 93 Rocky Brook Road, North Andover
Owner: Cablas
Date of Inspection: 10/1/1999
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.
Bateson Enterprises, Inc.
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PLAN REVIEW CHECKLIST
ADDRESS ,gyp% /� ��oC,��� ENGINEER
GENERAL
3 COPIES (/ STAMPj! LOCUS L�-' NORTH ARROW SCALE L/
CONTOURS(/ PROFILE L -- SECTION i� BENCHMARKS SOIL & gg /--
!0 /
PERCS ELEVATIONS ✓ WETS. DISCLAIMER �� WELLS & WETS �157mob
�` /
WATERSHED? /yo DRIVEWAY��Elev) WATER LINE FDN DRAIN P/ ASN
SCH40 V TESTS CURRENT? C/ SOIL EVAL
SEPTIC TANK
MIN 150OGy .17 INVERT DROPy GARB. GRINDER t/0 (+200%'EDF)
25' TO CELLAR C, -MANHOLE ELEV GW # COMPS.
D -BOX
SIZE # LINES FIRST 2' LEVEL STATEMENT
INLET a3.(0 % - OUTLET/,,60 / ( 2" OR .17 FT) TEE REQ' D? /Vd
LEACHING /
MIN 660 GPD? i/ RESERVE AREAL- 4' FROM PRIMARY? 1,�2% SLOPE
100' TO WETLANDS 0100' TO WELLS �� 4' TO S.H.GWX (5'>2M/IN)
35' TO FND & INTRCPTR DRAINS L,-' 325' TO SURFACE H2O SUPP /�
4' PERM. SOIL BELOW FACILITY-Zj/ MIN 12" COVER FILL?(/ (25'
if above natural elev; 101if below) BREAKOUT MET?
TRENCHES
MIN 660 qpd SLOPE (min .005 or 6"/100') SIDEWALL DIST. 3X EFF.
W OR D (MIN 6')(/ RESERVE BETWEEN TRENCHES? If IN FILL? r� MUST
BE 10' MIN. v 4" PEA STONE?>� VENT? /�t� (>3' COVER; LINES >501)
BOT + SIDE �u` o� X LDNG TOT
(L x W x #) (DxLx2x#) (G/ft2)
Copyright 0 1995 by S.L. Starr
r { �
t1�a g`
TO
STEVEN J. D'URSO
Environmental Designs
22 Lilly Pond Road
W. Boxford, MA 01921
(508) 352-9872
WE ARE SENDING YOU ❑ Attached ❑ Under separate cover via_
❑ Shop drawings ❑ Prints ❑ Plans
❑ Copy of letter ❑ Change order
LIEUTEIM 01F MUMUTUL
DATE
ATTENTION
the following items:
❑ Samples ❑ Specifications
COPIES ATE NO. DESCRIPTION
3.0
o� S
THESE ARE TRANSMITTED as checked
below:
❑
For approval
❑
Approved as submitted
❑
For your use
❑
Approved as noted
❑
As requested
❑
Returned for corrections
❑
For review and comment
❑
❑
FOR BIDS DUE
19
REMARKS
_
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
COPY TO
SIGNED:
It enclosures are not as noted, kindly notify us at once.
Town of North Andover
. OFFICE OF
COMMUNITY DEVELOPMENT AND SERVICES
KENNETH R. MAHONY
Director
146 Main Street
North Andover, Massachusetts 01845
(508) 688-9533
August 18, 1995
Steve D'Urso
22 Lilly Pond Road
Boxford, MA 01921
Re: Lot #15 Rocky Brook Road
This is to inform you that the proposed plans for the site
referenced above have been disapproved for the following reasons:
1) Need benchmark within 70 feet of system
2) Leach area bottom not 4 feet to groundwater
3) Need 4 inches of pea stone
If you have any questions, please do not hesitate to call the
Board of Health Office at the number above.
Sincerely,
Sandra Starr, R.S.
Health Administrator
SS/cjp
BOARD OF APPEALS 688-9541 BUILDING 688-9545 CONSERVATION 688-9530 HEALTH 688-9540 PLANNING 688-9535
Julie Parrino D. Robert Nicetta Michael Howard Sandra Starr Kathleen Bradley Colwell
:� IL' 7-,0 /5� 0 &-
STEVEN J. D'URSO
Environmental Designs
22 Lilly Pond Road
W. Boxford, MA 01921
(508) 352-9872
UMM"id =W-1
WE ARE SENDING YOU [Attached ❑ Under separate cover via
❑ Shop drawings
❑ Copyof letter
°�[ Prints
/❑_Change order
❑ Plans
❑
[LETTIEQ (01FITRZKOO UL
DATE JOB 149
ATTENTI N
RE
P 00
the following items:
❑ Samples ❑ Specifications
COPIES
DATE
NO.
DESCRIPTION
THESE ARE TRANSMITTED as checked below:
For approval ❑ Approved as submitted
❑ For your use ❑ Approved as noted
❑ As requested ❑ Returned for corrections
❑ For review and comment ❑
❑ FOR BIDS DUE _ 19
REMARKS
❑ Resubmit copies for approval
❑ Submit copies for distribution
❑ Return corrected prints
❑ PRINTS RETURNED AFTER LOAN TO US
COPY TO / , &A/14
SIGNED:
If enclosures are not as noted, kindly notify us at once.
DATE
Sheet of
BOARD OF HEALTH
TOWN OF NORTH ANDOVER
SUBSURFACE DISPOSAL DESIGN REVIEW
FEE PERMIT # DATE RECEIVED
APPLICANT
ADDRESS
ENGINEER
ASSESSOR'S MAP
PARCEL #
LOT #
STREETp /tf,
ADDRESS Z Z Zlc-G �'Pei x /'j '-p�
PLAN DATE REVISION DATE
CONDITIONS OF APPROVAL:
APPROVED
DISAPPROVED
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BOARD OF HEALTH
120 MAIN STREET TEL. 682-6483
NORTH ANDOVER, MASS. 01845 Ext23
February 16, 1995
New England Engineering
33 Walker Road, Suite 32
North Andover, MA 01845
Re: Lot #17 Rocky Brook Road
Dear Ben:
This is to inform you that the proposed plans for site
referenced above have been disapproved for the following reasons:
1)
Discrepancy with soil test information: If peres
are numbers 4 & 5, then design/perc rate is 5
minutes per inch. Peres 3 & 4 are both 2
nc.
zestions, please do not hesitate to ca- I
c.e at the number above. -
Sincerely,
Sandra Starr, R.S.
Health Administrator
BOARD OF HEALTH
120 MAIN STREET
NORTH ANDOVER, MASS. 01845
February 16, 1995
New England Engineering
33 Walker Road, Suite 32
North Andover, MA 01845
Re: Lot #15 Rocky Brock Road
Dear Ben:
TEL. 682-6483
Ext 2 3
41
This is to inform you that the proposed plans for site
referenced above have been disapproved for the following reasons:
1) Note that benchmark to be set within 50 feet of
the system prior to construction.
2) Concerned about breakout grading - 125.66. What
is distance to this grade @ Northern side of
system?
f you have any questions, please do not hesitate to call
th. Board of Health Office at the number above.
Sincerely,
C
Sandra Starr, R.S.
Health Administrator
SS/cjp.
PLAN REVIEW CHECKLIST
ADDRESS Z/ur�()LiC y-73/�. ENGINEER>c�U
GENERAL /
3 COPIES STAMP""/
CONTOURS PROFILE C--"
LOCUS NORTH ARROW L---' SCALE
y,
SECTION �� BENCHMARK P�'1�SOIL &
PERC INFO ELEVATIONS WETS. DISCLAIMER WELLS &
WETLANDS Z_,--'WATERSHED?DRIVEWAY �T_Elev) WATER LINE
FDN DRAIN-j� SCH40_ /_ TESTS CURRENT?
SEPTIC TANK / /
MIN 1500G Z./ . 17 INVERT DROP (/ GARB. GRINDERJ6 (+200% EDF)
25' TO CELLARy MANHOLE TO GRADE ELEV GW
D -BOX
SIZE # LINES A FIRST 2' LEVEL STATEMENT
INLET/Z(5,6 %- OUTLET/9-1,,5 _ l T ( 2" OR .17 FT) TEE REQ' D? /VO
LEACHING
MIN 660 GPD? RESERVE AREA 4' FROM PRIMARY? tom 2% SLOPE �r
100' TO WETLANDS 00' TO WELLS L,---"4' TO S.H.GW c�
35' TO FND & INTRCPTR DRAINS/ 325' TO SURFACE H2O SUPP C/
4' PERM. SOIL BELOW FACILITY �lMIN 12" COVER Ci__ FILL? 25'
if above natural elev; 10' if below) BREAKOUT MET?
1�3sG6
TRENCHES
MIN 660 gpd SLOPE (min .005 or 6"/1001)(/ .3 'COVER? -VENT
SIDEWALL DIST. 2X EFF. W OR D (MIN 61) _./ IS RESERVE BETWEEN
TRENCHES? L�IN FILL?`MUST BE 10' MIN.j__/4" PEA STONE?
BOT O X LDNG9-06 + SIDE (020 X LDNG L00= TOT96G "49t/vO
(L x W x #) (G/ft2) (DxLx2x#) (G/ft2)
Copyright C 1993 by S.L. Starr
101 VNIN
Will
'�1 �.j A,.. 'OM1.
Commonwealth of Massachusetts
Massachusetts
System Pumping Record
System Owner
/I b ( r ,) 0
System Location
ps
,l l
Date of Pumping: f ��-- � � Quantity Pumped:
Cesspool: No '7 Yes Septic Tank: 'No �.� Yes
System Pumped by: Farejea Srf&,fftiaea License #
Contents transferrred to: Greater Lawrence Sanitary District
Date:
Inspector
rOA c' rW IFr a �e' si
C. 2 2, jq,%
r,
William F. Weld
Governor
Argeo Paul Celluccl
U. Govemor
Commonwealth of Massachusetts
Executive Office of Environmental Affairs
Department of
Environmental Protection
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION
�
Property Address: 933 �( �' �p(>�f� Al/��`C`�Xl7Address of Owner.
Date of Inspection: ~(—- �" 1 (If different)
Name of Inspector. KJQl
Company Name, Address and Telephone Number. BATESON ENTERPRISES, INC.
Excavating - Water & Sewer Lines - Septic Systems & Pumping Service
111 A ilia Road A d
1!;`N OF iv051k,! -�YUOVt:r
LAUG , .- 71997
Trudy Coxe
David B. Struhs
Commissioner
TEL (508) 475-1474
FAX: (508) 475-5451
CERTIFICATION STATEMENT 0 n over, Mass. v, ,v
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is irue, 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 aewage disposal systems. The system:
✓p/asses
Conditionally Passes
Needs Further Evaluation By the Local Approving Authority
F'
Inspector's Signature: Date: I aD
The System Inspector shall su mit a cop f this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector• and the system owner shall submit the
report to the appropriate regional office of the Department of Environmental Protection.
The original should be sent to the system owner and copies sent to the buyer, if applicable and the approving authority.
INSPECTION SUMMARY:
Check A, B, C, or D:
A] 9� PASSES:
I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMA 15.303.
Any failure criteria not evaluated are indicated below.
B) SYSTEM CONDITIONALLY PASSES:
One or more system components need to be replaced or repaired. The system, upon completion of the replacement or repair, passes
inspection.
Indicate yes, no, or not determined (Y, N, or ND ). Describe basis of determination in all instances. If 'hot determined", explain why not)
The septic tank is metal, cracked, structurally unsound, shows substantial infiltration or exfiltration,.or tank failure is
imminent. The system will pass inspection if the existing septic tank is replaced with a Fonformrng septic tank as approved
by the Board of Health.
(revised 11/03/95)
One Winter Street • Boston, Massachusetts 02108 4 FAX (617) 560049 6 Telephone (617) 292-$500
ii Printed on Recycled Paper
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (c6naniied)
Property Address: -1
Owner.
Date of Inspection-
97 —-r 9
B) SYSTEM CONDITIONALLY PASSES (continued)
_ 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 pipets) are replaced
obstruction is removed
distribution boa is levelled 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
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 protest the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES 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 a surface water
Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt maish.
2) SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE)
DETERMINES THAT THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECT THE PUBLIC HEALTH AND
SAFETY AND THE ENVIRONMENT:
The system has a septic tank and soil -absorption system and is within 100 teei to it surface water supply or tributary to a
surface water supply.
The system has a septic tank and soil absorption system and is within a Zoiie I of a public water supply"+ well.
The system has a septic tank and soil absorption system and is within 50 feet of a private water supply well.
_ The system has a septic tank and soil absorption system and is less than 100 feet but 50 feet bi more Som 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.
3) OTHER
(revised 11/03/95)
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Property Address: q-3
Owner.
Date of Inspection:
D) SYSTEM FAILS:
I have determined that the system violates one or more of the following failure criteria as defined 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.
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 .eater analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
El LARGE SYSTEM FAILS:
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:
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 (rWPA) or a mapped Zone II of a public
water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater ireatment program
requirements of 314 CMR 5.00 and 6.00. Please consult the local regional office of the Department for further information.
(revised 11/03/95)
Property Addrebs:
Owner.
Date of Inspection:
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FOiiM
PART B
CHECKLIST
t' -x-47
Check if the following have been done:
t/Pum ing information was requested of the owner,. occupant, and Board of Health.
"None of the system components have been pumped for at least two weeks and the system has been recelv4M9normal flow rates
during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection.
_
As built plans have been obtained and examined. Note if they are not available with N/A
�e facility or dwelling was inspected for signs of sewage back-up.
The system does not receive non -sanitary or industrial waste flow
^ The site was inspected for signs of breakout.
V
/AU, components, excluding the Soil Absorption System. have beeii located on the site.
The septic tank manholes were uncovered, opened, and the ihterior of the septic tank was inspected for condition of hitdes or
tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
k l ne aize and location of the Soil Absorption System on the site has been determined baited on existing information or
7M
mximated by non -intrusive methods.
The facility owner (and occupants, if different from owner) were provided with information on the proper lnaintenanoe of Sub -
Surface Disposal System.
(revised 11/03/95) 4
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
' ` -�\��'��11 SYSTEM INF`O\RM�ATIO
Property Address: � �C`>✓� ��;
Owner. `� �i
Date of Inspection:
t
FLOW CONDITIONS
RESIDENTIAL:
Design flow: �ons
Number of bedrooms:
Number of current resident's: 4
Garbage grinder (yes or no):—W$
Laundry connected to system dyes or no):—yes
Seasonal use (yes or no): NO ,c 1ha
Water meter readings, if available: 4% a 3EooC�-3 x h,S
Last date of occupancy: l-.-VCC
115
COMMERCIAL/I NDUSTRLAL:
Type of establishment:
Design flow:----gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)
Non -sanitary waste discharged to the Title 5 systein: (yes or no)_
Water meter reading's, ,if available:
Lasa care of occupancy:
OTHER (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and source of information:
System pumped as part of inspection: (yes or no)_O
If yes, volume pumpedgallons
Reason for pumping:
TYPE STEM
Septic tank/distribution box/soil absorption system
Single cesspool
Overflow cesspool
Privy
Shared system (yes or no) (if yes, attach previous inspection records, if any)
Other (explain)
19 qq , - o w"&Q-qr
PPR�XI? ATE AG( f all components, date installed (if known) and source of informatioh:t' �/�S C.3� 'j � rqqS
1
Sewage odors detected when arriving at the site: (yes or no) �j®
(revised 11/03/95) 6
0
a SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Property Address: q3
Owner.
Date of Inspection:
SEPTIC TANK:
(locate on site plan)
Depth below grade: Ja u
Material of construction: —"'Cr, —metal _FRP —other(explain)
Dimensions: f 0AS
Sludge depth: D
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:
Distance from bottom of scute to bottom of outlet tee or baffle:
Comments:
(recommendation for pur
evidence of leakage, etc.)
(locate on site plan)
of inlet and outlet tees or
Depth below grade:
Material of construction: _concrete _metal _FRP —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:
in
to outlet
r ,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural integrity,
evidence of leakage, etc.)
F,
(reJised 11/03/95)
6
. 11
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (cont ued)
Property Address: Q'3 (jkc)c � �� j�1o`� ,�--
Owner.
Date of Inspection
TIGHT OR HOLDING TANK_"
(locate on site plan)
Depth below grade:
Material of construction: _concrete _metal _FRP _other(eaplain)
Dimensions:
Capacity: gallons
Design flow: gallons/day
Alarm level:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
DISTRIBUTION BOX. v
(locate on site plan)
Depth of liquid level above outlet invert: O
Comments: (�_ C1 _ �' a �,
/`rte if level and ributio is equal, evidence of solids /.����'�love�r ,e{'�77d�en�te of le into of AoAf box, T0c.) .V �,"..�_'�C �`'�J
l \ n C 11 . 1 ^ � n t�[� . _ . n /', 1 � / 11��. 1 �l \ n_ \ � V \ \1
11��1�T�s��i11`l�CCtr •��
PUMP CHAMBEIL-tl� .
(locate on site plan)
Pumps in working order:(ges or no)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 11/03/95) 7
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
a PART C
SYSTEM INFORMATION (continued) ,n ,
Property Address:
Owner.lk `� �' • wco( 1
Date of Inspections �. ` `
c? r7
SOIL ABSORPTION SXSTEM (SAS):_✓�
(locate on site plan, if possible; excavation not required, but may be approximated by non -intrusive methods)
If not determined to be present, explain:
Type:
leaching pita,' number:
leaching chambers, number:_
leaching galleries, number:
Q��� `"l
leaching trenches, number,length: 0 V `'
leaching fields, number, dimensions: ...!!!
overflow cesspool, number:
CESSPOOL9: r e
(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:
Mow (cesspool must be pumped as part of inspection)
Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY: le_
(locate on site pl)n)
Materials of construction: Dimensions:
Depth of solids:
Comments: (note condition of soil, 'signs of hydraulic failure, level of ponding, condition of vegetation, etc.
(revised 11/03/95)
a
SUBSURFACE SEWAGE DISPOSAL• SYSTEM INSPECTION FORM
z PART C
SYSTEM INFORMATION (continued)
Property Address: q,V 91) v�^- j�
Owner.
Date of Inspection
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include `ties to at least two permanent references landmarks or benchmarks
locate all wells within 100'
DEPTH TO GROUNDWATER
Depth to groundwater: �' feet
method of determination or approximation:
I
(42S1aY-)
(revised 11/03/95) 0
IMITSON r- --S INC,
septic Systems -- Fxcnvntliig --- Mildt A SeVvet I1100
'r I I -A e 5 1 iu3por-' C I oil kepat C
i3ropert-.y AddrOelsi qJ�<
bate of InsVect-jolit
MY tepnirt CallLailied hwrotii db@(j fib60f1ijt1.0A(§ it
(plarFilitoo of f-tittito iilmaq@ Mid tho rutittfollatAtk
or E11L- bxIntfilq 1j"IjOb NY61comi §uOt tevokc 1§600d
lintaottit to tneirdiy b8mad u0bil Oif
nw! I hereby diflo;i1m Ativ rufthat itipiotialott of
Yolit (jotto'llt 130PLItj lgygtoik'
ndLodofl hicotottood ifiei
to. tit to
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: 1,0-10'n;2,,
q3 �ocky �roa'�
J
(example: left front of house)
�4�fo4-4 kwsc-
DATE
OF PUMPING:1-0- (6 -6 .1, QUANTITY PUMPED-1�50D GALLONS
CESSPOOL: NO YES SEPTIC TANK: NO YES
-Z
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION
p:.
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: (7 ` L - �5` h>
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE•
�Cur
c[3�:ocl( Ia-ook Qj.
SYSTEM LOCATION
(example: left front of house)
DATE OF PUMPING: -OI QUANTITY PUMPEDGALLONS
CESSPOOL: NO YYES SEPTIC TANK: NO YES
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: . G_ z -- L
V
Commonwealth of Massachusetts
City/Town of
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.
A. Facility Information
1. System Location: Left/ Righ t of hou , Le / Right rear of house, Left / right side of house, Left /
Right side of building, Left / Right fronto ding, Left / Right rear of building, Under deck
Address �� �X/c,
/
pkk5ls�l ' `�' d_
Cityrrown State Zip Code
2. System Owner.
ucu
Name
Address (if d'dferent from location)
Citylrown
F
Telephone Number
r � �®Zip Code
B. Pumping Record
1. Date of Pumping Date 2., Quan Pumped: Gallons
r`
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No.
5. Condition of System:
6. System Pumped By:
Neil. Bateson
Name
Bateson Enterprises Inc
Company
7. Location Mere contents were disposed:
�- S• Lowell Waste Water
Vehicle License Number
NOV 19 M3
TOWN OF NORTI# A11gC
HEALTH DEPAff,44EI
Date
6o
t5fom4.doc• 06103 System Pumping Record • Page 1 of 1