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HomeMy WebLinkAboutMiscellaneous - 953 JOHNSON STREET 4/30/2018l Commonwealth of Massachusetts City/Town of System Pumping Record ,M Form 4 JAN-3'ZQ11 ITOWN OF NORTH ANDOVER I HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left front of house, right front of house, left side of hous , right side of hou , Left rear of house, right rear of house, left side of building, right rear of building, un er ec c. City/Town State 2. System Owner: Name Address (if different from location) Citylrown B. Pumping Record L _ � -(_(D 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date Cesspool(s) Zip Code State S_ Telephone Number — 2. Quantity Pumped: eptic Tank J'��� Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes LSO If yes, was it cleaned? ❑ Yes ❑ No 5. Condition ofSyste m:�1� 6. System Pumped By: .4 Neil J. Bateson Name Bateson Enterprises Inc. �Company f 7. Location w re contents were disposed: L.S.D. o II aste a Signature e F5821 Vehicle License Number �� - Lq-ly Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 C 1 LU12 DEP has provided this form for use -by local Boards of Heaw':1Other forms may be used, but the information must be substantially the same as that provided here. Before using Ahis 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 / Right front of house, Left / Right rear of house, Left right ide of hous Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Aaaress 9 — ' 3 - Sf-- City/town State 2. System Owner. Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Zip Code � 7 — a79 61 Zip r Code Telephone Number U --k12�_ Date 2. Quantity Pumped: Cesspool(s) eptic Tank Gallons ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Location where contents were disposed: Ca. Waste Water Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 t \ 1 � f f ♦ 1` L ` f i f' ,• r �4 r 12INN TO OF YSTEM PUMPING RECORD DATE: SYSTEM OWNER & ADDRESS !�611v\eJle Q 6-3 5) �v SYSTEM LOCATION (example: left front of house) ..� 5 L�-- qzslle DATE OF PUMPING: QUANTITY PUMPED: GALLONS CESSPOOL: NO YES SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: cowm1m TRANSFERRED To: G.L.S.D Lowell Waste ti `.f .._ i.; R Board of Health- *sEMC SISTEH North Anc_nverxMaaa. INSTAII•ATICK CHECK LIST LOT 4 'l© WED DATE • DISAPPt1(NID E) AVATIC�J f OKI, FAIL 10 RWaeonst FAIL OK 1. Distance Tot a. Wetlands f�Q b. Drains v C., Well 2. Water Line Location 3• No PPC Pipe !�. Septic Tank a. _Tess -_Length do To Clean Ont Covers. b. Cement Pipe to Tank On Both Sides of Tank 5• Distribution Box a. Covers & Box - No Cracks b. All Lines Flowing Equal Amounts c. No Back Flow 6. Leach FieldTrench a. Dimens' b. VStonDepthc. Eads d.Double Washed Stone 7. Leach Pits a. Dimensions / b. Stone Depth c. Splash Pads d. Tees e. Cement Pipe to Pit - Both Sides f. Clean Double Washed Stone 8. No Garbage Disposal. �. Final Grading Inspection 10. Barricading Covered System 11. As Built Submitted a. Lot Location b. Dimensions of System c. Location with Regard -to Pere Test d. Elevations e: Water Table woad of Health �.or4_j,, :.ndover�K.asa APPROVE DATE Provided: Title V I FAIL tIK Reg 2.5 F.eg 6 Reg 10.2 Reg 10.4 SUBSURFACE DI&POSAL DESIM CHECK LISP LOT DISAPPROVED DATE Reasons: .. - - F�e submitted plan Mast show as a minimum: the lot to be served-areapdimensions lotd#,abutters distance to ties location and log deep observe tion location and results percolation tests -distance to ties d design calculations & calculations showing r-equired leaching area Be ocation and dimensions of system -including reserve area fiexisting and proposed contours stem or g) location any wet areas Athin 100' of se, -,.-age disposal sy /disclairer-check wetlands mapping h)face and subsurface dr2ins within 100' of sewage disposal yurl /system or disclaimer J) location any drainage easementsn' of sc-s ge disposal �systen or disclaiMer-PIA-1-J ing Board files J) krto-,= sources of eater sImply within 200' of serge disposal. e ;;`� system or disclainer �ocation of rnp proposed ,--ell to serve lotom l chinfrom leaching facilj location of meter lines on property -10' from leaching facility ,location of benchmark driveways o) garbage disposals ,��"no PDC to be used in construction ,q) profile of system- eel.eva.tiors of basem~nt, plumb, pipe, septic tangy:, distribution box inlets and outlets, distribution field piping and Other elevations r nim ground aster elevation in area sewage disposal system ,s plan must be prepared by a Professional Eaginser or other professional authorized by law to prepare such plans Aseptic Tanks ^citie s -150T of flow, nater table, tees, depth of tees, Ca�3G access, pu ,Ding cleanout ool lot from cellar -,ail or in,group d s� mII"- g P 25+ from s°sbsurface drains Distribution Fares slope greater than 0.08 SUIT Sh bsurface I3?sip I Mu Reg 15.1 15.1 15.8 3.7 Check•List I CK I Leaching Pits cft� 0 Leaching pits are preferred where the installation is possible a) calculations of leaching area -rd ni=,m 500 eq ft b) spacing c surface drainage 2% d cover material e) 2 i x2 l x4" splash pad f) tee at elbow g) no beds in pipe from d -box to pipe Leaching Fields a) no grRater 20 minutes/inch b) 900 sq ft c) coags tion of field d) ce drainage 2 % e) 201 .from cellar or inground swimming pool Leaching °Troches Reg 14.1 a) cacv� on eaching area -min 500 sq ft 14.3 b) spacing- t imin 6 ft with reserve between 1l�.ls c) dlm~�-�. ns 1t�.6 d) co tction l.tl.7 e) ene It -.10 f �urfac9 rirainage 2% Do -=hill l Slo e a) Slope x= to be s_h•o-km) b) y/x X 150 = (to be shoran) n�.-Ds Reg 9.1 a) approval 9.6 ��� b) stand-by power SOIL PROFILE & PERCOLATION TEST DATA North Andover, Mass. Street No SOA N Sc�,tJ ST Lot No p Loc/Subdiv. Pland Owner Lotip VEST Investigator S��-'�oc� Observer x'1512. SOIL PROFILE DATES l.El.ev 2.Elev 3.Elev 4.Elev s12g18 S. Tt S c�¢.av EL Benchmark Elevation 1 1 2 2 3 3 �UE1E 4 y 4 5 6 7 8 1�`IZ 5 6 7 8 Start Saturation 10 : 4L 9 9 No wasE� 10 10 DATES Location Datum PERCO;,ATION TESTS c.1-71 a3 (tI-, I OS 2 3 4 5 6 7 8 9 10 Tiles Pis est Pit Number 1�`IZ 2 3'It 3 4 Start Saturation 10 : 4L 10'. 3co Soak -Minutes lO.-97- Start Test=Tlme11:01 Drop of 3" -Time tco Drop of 6" -Time Z Mms.lst 3" drop Q Mins.2nd " DropIS Percolation S J o 1�rN sc a� sT' CD e> lot psi Commonwealth of Massachusetts City/Town of I ` IVSystem Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The System Pumping Record must be submitted to the local Board of Health or other approving authority. . A. Facility Information Important: When filling out 1. System Location: forms the computer. use only the tab key Address Is 3 to move your d cursor - do not use the return Cih'ffown State key. 2 System Owner: Name Address (if different from -location) l� City. frown State o Telep one Number http://www.i 3. Pumpi' Record 1. .Date. of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) peptic Tank- ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑Yes ❑ No 5. Condition of System: t5form4.doc- 06/03 Commonwealth of Massachusetis 1U, i"W(Massachusetts System Pumping Record System Owner ! C�aA 19 System Location Date of Pumping: L���/ �� Quantity Pumped: k6-4� gallons Cesspool: No Yes Septic Tank: No U Yes System Pumped by: Stre44r6 &e.&W �taa License # Contents transferrred to : Greeter Lawrence saniterb District Date: Inspector: 4.