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HomeMy WebLinkAboutMiscellaneous - 96 FARNUM STREET 4/30/2018 (2)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/ Right front of house, Left / rear of houseLeft / right side of house, Left / Right side of building, Left / Right front of building, Left / Ig rear of building, Under deck Address ---� City/Town state Zip Code 2. System Owner. Address (if different from location) CitylTown Zip Code 23 2 �. A R R 2 12015 Telephone Number TOWN OF NORTH ANDOVER B. Pumping 1. Date of Pumping 3. Type of system: V■ M Date 2. Quantity Pumped: Gallons ;. ❑ Cesspool(s)Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑Yes Id" No If yes, was it cleaned? ❑ Yes ❑ No: 5. Condition tem: 6. System Pumped By. Neil. Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc- Company ncCompany 7. Loca�fo , contents were disposed: Lowell Waste Water ul Date t5form4.doc- 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts V City/Town of RECO VE System Pumping- Record NOV 2014 Form 4 FiUR04 HEAT. N ® A VER DEP has provided this form for us&by local Boards of Health. Other forms 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 / Right front of house, Le of h , Left / right side of house, Left / Right side of building, Left / Right front of building, Left i Right rear of building, Under deck Address city/Town C/W S Zip Code 2. System Owner Name Address (if different from location) citylrown ' State ' Zin CodeLf ; Telephone Number B. Puimping Record 1. Date of Pumping 2. P 9 Date Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s)afeptic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yeas o if yes, was it cleaned? ❑ Yes ❑ No: 5. Condition of stem: 6. System Pumped By. - Nell y: Neil. Bateson Name Bateson Enterprises Inc Company - 7. Loca ' ere contents were disposed: Cyi _ Lowell Waste Wc- t5formCdoe- 06/03 F5821 Vehicle License Number -LAI""� ✓�`� Date System Pumping Record • Page 1 of 1 1�4 Commonwealth of Massachusetts Ree '' City/Town of DEC 2011 System Pumping Record TOWN OF NORTH ANDOVER Form 4 HEALTH DEPARTMENT 1M Sv. 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 / Right front of house, Left i ht rear of hous , Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address City/Town State 2. System Owner: V)c- E \Uv�'-e Name Haaress kn airrerent from location) Cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ Zip Code State„ � 1 , l � 7� Code Telephone Number Date 2. Quantity Pumped Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locat' where contents were disposed: G.L,,S.p Lowell Waste Water Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date c)- _' f -- I( t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts City/Town of V' System Pumping Record Form 4 _.,, , n DEP has provided this form for use by local Boards of Health. Other form 1mae�used abut the` information must be substantially the same as that provided here. Before usi I T is fom�i,; h vitt , our 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 I ar of ho�l . , Left/ right side of house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address State 2. System Owner. Name Zip Code Address Cd different from location) City/Town Stat � Ziu Code Telephone Number B. Pumping Record 1. Date of Pumping Date 2. Quantity Pumped: - Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank 1:1 Tight Tank 4. ❑ Other (describe): Effluent Tee Filter present? F1 Ye D -Mo If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition V\ j7r-Ak-�� 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc- company nccompany 7. Locati ere contents were disposed: Lowell waste m F5821 Vehicle License Number Date Lf—f&I/ q t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 11 Commonwealth of Massachusetts City/Town of System Pumping Record Form 4 OCT 2013 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using.this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left / Right front of house, Left ear of hous. , Left/ right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address 00�q-/(k P:�47 Citylrown State Zip Code 2. System Owner. Pck �, \ E Name Address (if different from location) Citylrown Stat p Code Telephone Number -` B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes 9-9�0 If yes, was it cleaned? ❑ Yes ❑ No. 5. Condition o, � f $ySt�e`�V��� 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatio wh a contents were disposed: Lowell Waste Water Date t5fbrm4.doc• 06103 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of JUN 2 Q 2013 Pumping System in Record Y N � TOWN OF NORTH ANDOVER Form 4 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 / Right front of house, Left /fit r of hq, e, Left / right side of house, Left / Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address % r S;�- o City/Town State Zip Code 2. System Owner. Name Aaaness (it aitterent from location) cityrrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ p�IOJA'o StattS2 --Zip Code Telephone Number "[ �g-(9--k3 — 2. Quantity Pumped Septic Tank Date Cesspool(s) ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No Gallons ❑ Tight Tank If yes, was it cleaned? ❑ Yes ❑ No, 5. Condi! 7, 0of stem: l I��c J ✓\ 6. System Pumped By: Neil Bateson F5821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Loca*=Aoere contents were disposed: Ca L S. Lowell Waste Water wl- bzbm-e-�0 G� luleq j Date t5fortn4.doc• 06/03 System Pumping Record • Page 1 of 1 '�N- Commonwealth of Massachusetts o- City/Town of W° System Pumping Record G„M S 0,v 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 = t"Wforrn th711 �` tii your local Board of Health to determine the form they use. The System Pumpi g Re l a�slt mi d to the local Board of Health or other approving authority. A. Facility Information TOWN OF NORTH ANDOVER 1. System Location: Left front of house, right front of house, left side of,VZ&9F �d�6eft rear of hous , right eear of house ft side of building, right rear of building, under deck '1(e 4a� City/ I own State Zip Code 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record State Zip Code Telephone Number 1. Date of Pumping Quantity Pumped: f (7) 6 C) Date Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes [9 No 5. Condition of System: 6. System Pumped By Neil J. Bateson Name Bateson Enterprises Inc. Company 7. Location where contents were disposed: G.L.S. Lowell Waste Water n c A Signature of Hauler t5form4.doc• 06/03 If yes, was it cleaned? ❑ Yes ❑ No F5821 Vehicle License Number Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts RECEIVED City/Town of S E P o 8 2009 a System Pumping Record Form 4 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left side o house, Right side of house, Left front of house, Right front of house, Left rear of ho Ig F ar of house. Address City/Town 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): V) U -f - State I C,-\f\e ©Gk/A^ .4r, Zip Code StateZip Code �, -3--1 Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes L IN`O/ 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location whe a contents were disposed: .L. .D Lowell Waste Water Pmt If yes, was it cleaned? ❑ Yes ❑ No Vehicle License Number F5821 Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts t City/Town of System Pumping Record OCT 1 2 2006 Form 4 r A [ OVER 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 AddressC— to move your cursor - do not Ci use the,retum ty/Town State Zip Code key. 2. System Owner: ^^ll a - VV\.� Name Address (if different from location) CityfTown State Zip Code Telephone Number .B. Pumping. Record 1. Date of Pumping Date Quantity Pumped - Gallons 3. Type of system: ❑ Cesspool(s) eptic Tank ❑ Tight Tank- ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes D_No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: 6. Systyupy Namevehicle License Number vv� Company 7. Locatio hereec rntelzts,,wel-posed: � r ....... ., ,)rum, I Date — http://www-mass. gov/dep/water/approvals/`t5fonns. htm#inspect t5form4.doc• 06103 System Pumping Record • Page 1 of 1 TOWN OF A) A ch �[ nr SYSTEM PUMPING RECO DATE: 6 -,i- b S SYSTEM OWNER & ADDRESS IV: AUG 0 5 2005 TOWN OFNORTH A'.'UOVER HEALTH DEPARI�+'ENT SYSTEM LOCATION (example: left front of house) C i�4-f Mack o�` ktuts-� DATE OF PUMPING: 9-q- WS QUANTITY PUMPED : Ub ®n GALLONS CESSPOOL: NO YES PTIC TANK: NO YES :27 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 (EXPLAES) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: G.L.S.Dy Lowell Waste Commonwealth of Massachusetts City/Town of System Pumping Record \A 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. A. Facility Information Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. � 1�1 nein 1. System Location: Address Citylrown 2. System Owner: Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): c� �-t- lAd, 04 State �OAf- Zip Code State Zi Code Telephone Number Date 2. Quantity Pumped: Gallons Cesspool(s) eptic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: � r of � 6. Syste Pu pfd By: Namel Vehicle License Number s Conpan 7. Locationre ont a isposed: Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1 FORM U - LOT RELEASE FORM INSTRUCTIONS: This form is used to verify that all necessary approvals/permits from Boards and Departments having jurisdiction have been obtained. This does not relieve the applicant and/or landowner from compliance with any applicable or requirements. APPLICANT FILLS OUT THIS SECTIO APPLICANT i Y i O n PHONE�'ZUMV 3� LOCATION: Assessors Map Number ! /4 PARCEL SUBDIVISION LOT (S) STREET_'?o J,/, ST. NUMBER OFFICIAL USE ONL RECOMMENDATIONS OF TOWN AGENTS: CONSERVATION ADMINISTRATOR DATE APPROVED DATE REJECTED COMMENTS TOWN PLANNER DATE APPROVED DATE REJECTED COMMENTS MSP CTOR T DATE APPROVED , _ G ,� ,// DATE REJECTED DATE APPROVED PUBLIC WORKS - SEWERIWATER CONNECTIONS DRIVEWAY PERMIT FIRE DEPARTMENT RECEIVED BY BUILDING INSPECTOR DATE_ RevbW W jm I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: lb i Wor 5%, IN, Owner: fii/pff# // (1%"Q- Date of inspection: S I ?� (`ill 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) revised 9/2/98 Page 10 of Ll 3 sm3w Paec# ��3ovE �Q)v�wAy NEW ENGLAND ENGINEERING SERVICES INC June 7, 1999 North Andover Board of Health Town Hall Annex 27 Charles Street North Andover, MA 01845 RE: TITLE V REPORT: arnum Street, North Andover Enclosed is a copy of the Title V report for the above referenced property. The system passes our inspection. If there are any questions please call me at my office, 686-1768. Yours truly, Benjatiiin C. Osgood Jr., E.I.T. President 1 OWN OF NORTH ANDOVER/ t BOARD OF HEALTH JUN - 9 1999 4 33 WALKER ROAD -SUITE 23- NORTH ANDOVER, MA 01845 - (978) 686-1768 - (888) 359-7645- FAX (978) 685-1099 e COMMONWEALTH OF MASSACHUSE'Y'TS EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS Uq DEPARTMENT OF ENVIRONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292-5500 TRUDY COXE Secretary ARGEO PAUL CELLUCCI DAVID B. STRUHS Governor Comn-icsioner SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION Property Address: Mk/VpY1 bi , / iL� agND��Ei2 Name of Owner To" ? -11 1+1LN 1r-2 Address of Owner: 4C, N IbVat-� Date of Inspection: S L 2l' 9 G / Name of Inspector: (Please Print) Benjamin C. Osgood, Jr I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000) cornpariy Name: New England Engineering Services Inc. MaingAddress: 33 Walker Rd Sui M, Nnrt•h Andover, MA 01845 Telephone Number: 978-686-1768 CERTIFICATION STATEMENT 1 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-sitesewagedisposal systems. The system: 'l Passes Conditionally Passes _ Needs Further Evaluation By the Local Approving Authority _ Fails Inspector's Signature: �� Date: The System Inspector shall submit a copy othis inspection report to the Approving, Authority (Board of Health or DEP)wirthin 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 oKinvironmental Protection. The original should be sent IOVM system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS revised 9/2/98 Page I of 11 h `�! Pnnled on Recvcltd Papr, SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: 4(o Owner: -fol rN Date of Inspection: ✓ 121( q 1p INSPECTION SUMMARY: Check A, B, C, or D! A. TEM PASSES: 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 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. Indicate yes, no, or not determined (Y, N, or ND). 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($) 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 levelled or replaced The system required pumphig-Tnore than fourtfines a yeardue to broken or obstructed pipe(s). The sy$tem WHI V011-5 inspectionif (with approval of the Board of Health): - broken pipe(s) are replaced obstruction is removed revised 9/2/98 P2ge2ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address:lb AIAIVIJW ST l /1 &06160- owner: ji,/'?/N lticKlfie. Date of 4upection: 51 z 10-' 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.PRQIECT THE PUBLIC HEALTRAND SAFETY ANQ THE ENIOBONMEN:T- 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 end 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 3of II SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued) Property Address: p Fd NV ' S%l 1'v, f1N/�J re Owner: I _ cl0/%# 1111- -11ie Date of Inspection: S-1 Zr 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 irdo facility-or-s"tem component due tto an overloaded or vWgged SASor•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 112 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 ie -within 200 feet of-e-t#ilmary-4o a &urf&o&-d#4*-i *g -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 P2ge4ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST Property Address: flqZnv1yr Si. I /I). Owner: t ri­'P//77' lyl" eW I Date of Inspection: 67! ZII Qy Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following: Yep No Pumping information was provided by the owner, occupant, or Board of Health. None of the system -compooants.kaw !»en poaM"d+foratJeast two aw*&k4 and•thevystom hasA wo=cataiwg w smaw lfow rates during that period. Large volumes of water have not been introduced into the system recently or as part of this inspection. �R As built plans have been obtained and examined. Note if they are not available with N/A. The 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. ✓ All system components, excluding the Soil Absorption System, have been located on the site. _✓ _ 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: ✓ Existing information. For example, Plan at B.O.H. f _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115.302(3)(b)) _ The facility owner (and.occupaats.if different from..nwrner),iware,przmidedawith infnrmntiooLDn thn prnper:3n.en.n_.._ .,f SubSurface Disposal Systems. revised 9/2/98 P2ge5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address: 4& 6fI2NV:� ST. j A/. 9 Vda-cle Owner: �ruP ll+ V14.A. E e Date of Inspect o � 124I `N FLOW CONDITIONS RESIDENTIAL: Design flow: g.p.d./bedroom. Number of bedrooms (design): = Number of bedrooms (actual):_S Total DESIGN flow Number of current residents: % Garbage grinder (yes or no):r Laundry (separate system) (yes or no)lvo ; If yes, sepawe inspection required _ Laundry system inspected (yes or no) Seasonal use (yes or no):_ Water meter readings, if available (last two year's usage (gpd): rcno./V Sump Pump (yes or no): Nd Last date of occupancy: COMMERCIAUINDUSTRIAL: Type of establishment: Design flow: qpd 1 Based on 15.203) Basis of design flow Grease trap present: lyes 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: System pumped as part of inspection: lyes or no)_ If yes, volume pumped: gallons Reason for pumping: 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 instaNed{if known) -and source o44Mormation: tli-j rr T 2,0 Y9 S . PER C�c uNL~R Sewage odors detected when arriving at the site: lyes or no) i" revised 9/2/9$ P2ge6orii SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 iA"vw> $r / A - .J/V!atf-' e Owner: T i/ J iTN f!/t /!/',— Date of Inspection: y 1 z,1 qq I BUILDING SEWER: (Locate on site plan) Depth below grade:_ Material of construction: _ cast iron _ 40 PVC _ other (explain) Distance from) private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of feakage,-etc.) Pipc aruDE?- SL -+(3 //V, f s�cA.t�Ni SEPTIC TANK:_ (locate on site plan) iY Depth below grade: Material of construction: _'concrete _metal _Fiberglass _Polyethylene _other explain) If tank is (natal, list age _ Is.age.confrmed by Certificate of Compliance _ (Yes/No) Dimensions: /40t7' f/-.fcccws Sludge depth: G '" Distance from top of sludge to bottom of outlet tee or baffle: d 6 / - Scum thickness: 't / it 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 dimensions were determined: mFgS-�vycl J7cK Comments: (recommendation for pumping, condition of inlet and outlet tees or -baffles. depth of liquid level in relation to outlet invert, structur&Hntegrity. evidence of leakage, etc.) %.vfc /,r .'> , SCH 4c-- TZ.E /S x/c w GREASE TRAP:__jt/fj (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: (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.) revised 9/2/98 Pogr7ofII SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: *IV AWN1409 S/. , Owner: JV O r T/{ Hi a.V C Z Date of Inspection: TIGHT OR HOLDING TANK: JV4 (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: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTION BOX: (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) — PUMP CHAMBER: (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.) revised 9/2/95 p2geaofII SUBSURFACE SEWAGE QISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: 46 fAtuvm y, , N. Mhve,4 Owner: 7v?l/?/ /III wi:p2 Date of Inspection: sj z l6iy i SOIL ABSORPTION SYSTEM (SAS):_ (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: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.) oeejIEt> nvF-�F�i��, iE.�+cN '(r, Ivc, wA7EiL r" P17 4T iNS�CT7vN- CESSPOOLS: -&h (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: (note condition of soil, signs of hydraulic failure, level of pending, condition of -vegetation, etc.) PRIVY: NW (locate on site plan) Materjals of construction: Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) revised 9/2/98 Pnge9of 11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Address: Owner:.✓ai/# Date of Inspection: 3 l ?r l9y 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) revised 9/2/98 Page 10 of II 3 se�so� �cRcN Nr%�F -DQ) ve"q SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION (continued) Property Addr"z:,tMAW Owner: h9i ff/ )fm w Date of kupection: 51 Z i l -1- NRCS Report name 610ale - r 5, Z-* Co sac C Soil Type_ C Typical depth to groundwater USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope 2-1> Surface water A),.' A f Check Cellar N-'> S. Shallow wells y1c-, e Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property, observation hole, basement sump etc.) Determined from local conditions 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) /•� %�Ff/ G'F �'/TS dL//Lj C�/Y it/LG5/Of. �/rs f%)C'E i /LLEv /�if?llti!(•'�i revised 9/2/98 Page 11 of 11 I TOWN OF .._" SYSTEM PUMPING RECORD �� 2 8 { DATE:�� SYSTEM OWNER & ADDRESS SYSTEM LOCATION (example: left front of house) fi�gk�— bacv- G-F-U DATE OF PUMPING: — QUANTITY PUMPED : CESSPOOL: NO YES SEPTIC TANK: NO NATURE OF SERVICE: ROUTINE EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER f GALLONS YES FULL TO COVER BAFFLES IN PLACE LEACHFIELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: ` L ` T3 N O U a) tEE ro0 JA H t- 0 N 4-J 2 F -F 1 = f _o Q ;v u 0 Q w 0 m H no. L 7 a _ o EC v ,O m O D O Q 1 IV i T.+ F- O t 4 41Q E U 0 G, Z 1c a Common wealtth of Massachusetts -An dO 0-f, _, Massachusetts Sstem Pumping Record System Owner P � ff 0 n� Date of Pumping: ) 0 ,O— o iD Cesspool: No Hll� Yes U System Location Quantity Pumped: gallons Septic Tank: No U Yes L System Pumped by: Fetredda 5immIniw License # Contents transferrred to : Greater Lawrence Sanitary District Uate: _ Inspector: ARGEO PAUL CELLUCCI Governor COMMONWEALTH OF MASSACHUSETTS EXECUTIVE OFFICE; OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF E. VMONMENTAL PROTECTION ONE WINTER STREET, BOSTON MA 02108 (617) 292.5500 r TRUDY CORE Secretaq DAVID B. STRUHS Commiss'.ont. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION 9� FAk'xum si. ,¢N04W4 Property Address: Name of Owner Address of Owner: (74, fi'aiZNfiH'1 S,r- A/. 16yi ase Date of Inspection: sl2t `cl 9 Name of Inspector: (Please Print) Benjamin C. Osgood, Jr 1 am a DEP approved system inspector pursuant to Section 15.340 of Tilde 5 (310 CMR 15.000) Company Name: New England Engineering Servi res Inc. MaangAddress: 33 Walker Rd., Suite ?I- North Andover, MA 01845 Telephone Number: 978-686-1768 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: L. -/Pas s es Conditionally Passes Needs Further Evaluation By the Local Approving Authority ' _ Fails Inspectors Signature: (� Date: The System inspector shall submit a copy othis inspection report to the Approving, Authority lBToaard of Health or DEP)w•rthin 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 oKnvironmental Protection. The original should•be sent to•Ztm system owner and copies sent to the buyer, if applicable, and the approving authority. NOTES AND COMMENTS r + r r ! r I I I revised 9/2/98 Nze I or 11 A �1 Vnnted on KrcKkd PIP" SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY ADDRESS: 96 FARNUM ST. PART A ' NORTH ANDOVER, MA CERTIFICATION (continued) ` i OWNER: JUDITH HILNER DATE OF INSPECTION: 5/21/99 INSPECTION SUMMARY: Check A, A C, or D: A. SY TEM PASSES: 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 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. Indicate yes, no, or not determined (Y. N, or ND). Describe basis of determination in all instances. It '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 exfil.tration, 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: t 1 r i t l 1 Sewage backup or breakout or high static water level observed in the distribution box is due to broken or, obstructed pipe(:) 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 levelled or replaced _ - The system required pumpi More than fotrr-rimes a yeerdue to broken or obstructed pipe(s). The vysten will pa.. inspection if (with approval of the Board of Health): - - broken( Pi e s► are replaced P . obstruction is removed r r r r I i r i i I r 1 l revised 9/2/98 Page 2ofII MIRSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY ADDRESS:.96 FARNUM ST PART a NORTH ANDOVER, DSA cERnm noN (continued) OWNER: JUDITH HILNER DATE OF INSPECTION: 5/21/99 s • 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 SYSTEMA IS NOT FUNCTIONING IN A MANNER WHICH- MLL PROTECT THE PUBUC UEALTH.AND SAFETY ANQ THE ENvis0NMEBCT. _ 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 PR07CTS THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: i 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 r r r r revised 9/2/98 Page 3of11 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PAFIT A CERTIFICATION. (continued) PROPERTY ADDRESS: 96 FARfgUM ST NORTH ANDOVER, MA OWNER: JUDITH HILNER ! DATE OF INSPECTION: 5/21/99 1 I 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 eewege irtto4ecility-or-v"tem eomponent•due %to an overloaded orcleggod SAS,or�ceespool. 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. i j 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 ofthe 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: r r r r Yes No i j the system is within 400 feet of a surface drinking water supply the system -ie within 200 feet o�ery-to a aur(eoa drinkir►g wester sup*ly -- • --- •• - — 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 f office of thelDepartment for further infortltation. I I revised 9/2/98 Page 4of11 I ' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B CHECKLIST PROPERTY ADDRESS: 96 IFARNUM ST NORTH ANDOVER, MA OWNER: JUDITH HILNER DATE OF INSPECTION: 5/21/99 revised 9/2/98 Page 5ofII I Check if the following have been done: You must indicate either 'Yes" or 'No" as to each of the following: Yee No by Board Health. Pumping information was provided the owner, occupant, or of None of thi system ,compoa4nu.l.auab"n puaN"d+toratlsast two wwJu and•thw yctsm h&66aeoasceia;og wwss� lfow 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. _ The 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. ✓ _ All system components, excluding the Soil Absorption System, have been located on the site. _ 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 scrim. ; The size and location of the Soil Absorption System orr the site has been determined based on: I, Existing information. For example, Plan at B.O.H. f _ Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is unacceptable) 115:302(3)(b)l _ The facility,owner (and.occupaots.if different from-,owner).wareprnuided.with information.Dn t a rnnar rnR4ajana0t a �f Subsurface Disposal Systems. i 1 � revised 9/2/98 Page 5ofII SUBSURFACE SEWAGE DISPOSAL SYSTEMA INSPECTION FORM PART C PROPERTY ADDRESS: 96 FARNUM ST SYSTEM-WFoRfMAT1oN NORTH ANDOVER, MA OWNER: JUDITH HILNER DATE OF INSPECTION: 5/21/99 FLOW CONDITIONS RESIDENTIAL• Design flow: g•p•d./bedroom. �^ Number of bedrooms (design): = Number of bedrooms (actual): J Total DESIGN flow Number of current residents: Garbage grinder (yes or no): r Laundry (separate system) (yes or noNvo If yes, separate inspection required _ Laundry system Inspected (yes or no) Seasonal use (yes or no):_ Water meter readings, if available (last two year's usage (gpd): reiVIAl Sump Pump (yes or no): No Last date of occupancy: CyAen.,,! COMM rRCIAL/INDUSTRIAL: Type of establishment: Design flow: qpd ( 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: i OTHER: (Describe) Last date of occupancy: , GENERAL INFORMATION PUMPING RECORDS and source of information: System pumped as part of inspection: lyes or no)_ If yes, volume pumped: gallons Reason for pumping: TYPE OF SYSTEM . X Septic tank/distribution box/soil absorption system Single ce#spool 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 contrac{ Tight Tank . Copy of DEP Approval i Other APPROXIMATE AGE of all components. date instaHed{if known) -end source 04-wormation: Arm % 2D YfZi . PEr2 Uc e�NE.e Sewage odors detected when. arriving at the site: (yes or ono) revised 9/2/98 Page 6of II qk P1. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY ADDRESS: 96 FARNUM ST PART C :NORTH ANDOVER, MA SYSTEM INFORMATION (continued) ' t 'OWNER: JUDITH HILNER ' DATE OF INSPECTION: 5/21/99 :BUILDING SEWER: (locate on site plan) Depth below grade: Material of construction: _ cast iron _ 40 PVC _ other (explain) Distance frortl private water supply well or suction line Diameter Comments: (condition of joints, venting, evidence of leakage, -etc.)• - pipe OP(0CtX $uFi3 //�( f3RSCci4tENT SEPTIC TANK:— (locate on site plan) X Depth below grade: 42 Material of construction: _'concrete _metal _Fiberglass _Polyethylene _other(explain) If tank is Inetal, list age _ Is.age.confirmed by Certificate of Compliance _ (Yes/No) Dimensions: Sludge depth: G �� Distance from top of sludge to bottom of outlet tee or baffle. dt3 Scum thickness: a Distance from top of scum to to'p of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: How dimensions were determined: i+rF.gS %.zriy� S�T�K Comments: (recommendation for pumping, condition of inlet and outlet tees or- baffles. depth of liquid level in relation to outlet invert, structur&F4ntegrity. evidence of leakage, etc.) CC1,--1o1.".vA1 SCN 4C;' Tifk /S /YEisi GREASE TRAP: LV (locate on site plan) Depth below grade:_ Material of construction: _concrete _metal _Fiberglass _Polyethylene _other(explain) Dimensions: Scum thickness: r r r i Distance from top of scum to top 4f outlet tee or baffle:' • i Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: 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 linkage, etc.) revised 9/2/98 Page 7orit it SUBSURFACE SEWAGE. DISPOSAL SYSTEM JNSP.ECTION FORM PART C . PROPERTY ADDRESS: 96 FARNUM ST, SYSTEJN INFORMATION (continued) ' NORTH ANDOVER, MA . OWNER: JUDITH HH.NER DATE OF INSPECTION: 5/21/99 TIGHT OR HOLDING TANK:JV4 (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: (condition of inlet tee, condition of alarm and float switches, etc.) DISTRIBUTIONBOX:/V D -X (locate on site plan) Depth of liquid level above outlet invert: Comments: (note if level and distribution is equal, evidence of solids carryover, evidence of leakage into or out of box, etc.) PUMP CHAMBER: (locate on site plan) Pumps in working order: (Yes or No) Alarms in working order (Yes or No) Comments: (note con Idition of pump chamber, 4ondition of pymps and appurtenances, etc.) i I I l � i revised 9/2/98 Page R of 11 i 1 SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PROPERTY ADDRESS: 96 FARNUM ST PART C ` NORTH ANDOVER, MA SYSTEM INFORMATION (eonti6ued) OWNER: JUDITH HILNER DATE OF INSPECTION: 5/21/99 SOIL ABSORPTION SYSTEM (SAS) (locate on site plan, if possible: excavation not required, location may be approximated by non -intrusive methods) If not located, explain: Type: leeching pits, number: 2iN'`9Pi TS leaching chambers, number:_ leaching galleries, number:_ leaching trenches, number, length: leaching fields, number, dimensions: overflow cesspool, number:_ Alternative system: Name of Technology: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc A UPEKE Z> nvt ,zF� cK� i,ZA<N P r , 1440 cu .4-Mi4 it,( PrT i4 /NSr"Fcr?vN. CESSPOOLS: (locate on site plan) i Number and configuration: Depth -top ofliquid 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: (note condition of soil, signs of hydraulic failure, level of ponding, condition of.vegetation, etc.) =- PRM(- Nlf r r (locate on site plan) Materjals of construction; Dimensions: Depth of solids: Comments: (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation; etc.) revised 9/2/98 Pare 9 or i l SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION`(contitwed) PROPERTY ADDRESS: 96 FARNUM ST NORTH ANDOVER, MA OWNER: JUDITH HILNER DATE OF INSPECTION: 5/21/99. , 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) I, revised 9/2/98 3 siA34N A09c# Hr3avE r ' I SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C PROPERTY ADDRESS: 96 FARNUM;ST ;SYSTEM INFORMATION (corTtirwed) ' NORTH ANDOVER, MA OWNER: JUDITH HILNER DATE OF INSPECTION: 5/21/99 1 1 NRCS Report name 50.% r-.)R✓c F5!.f-L,,sc t.r.. cstin Soil Type_ C Typical depth to groundwater > (e USGS Date website visited Observation Wells checked Groundwater depth: Shallow Moderate Deep SITE EXAM Slope 2 •% �+ Surface water Alo Check Cellar .✓-D s - Shallow wells N ; Estimated Depth to Groundwater 10 Feet Please indicate all the methods used to determine High Groundwater Elevation: Obtained from Design Plans on record Observed.Site (Abutting property. observation hole. basement sump etc.) Determined from local conditions 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'Elovation. (Must be completed) �•) n FA C F PiTs r3ci •moi � c�N /f-i� c 5 iOE. �' � TS � E Fi c c E: � i,°�Pavrvi ' I I I I i I I revised 9/2/98 Page II or It TOWN OF M , . it SYSTEM PUMPING RECORD DATE: oZO—O� .i 2 ? ?C?3 SYSTEM OWNER & ADDRESS �Ck- �oAe SYSTEM LOCATION—�"` (example: left front of house) fI IV4- �,a - 6,js-e- DATE OF PUMPING: ^ Q QUANTTTY PUMPED: (Q GALL NS CESSPOOL: NO YES—_,,,SEPTIC TANK: NO YES NATURE OF SERVICE: ROUTINE J EMERGENCY OBSERVATIONS: GOOD CONDITION HEAVY GREASE ROOTS EXCESSIVE SOLIDS SOLIDS CARRYOVER FULL TO COVER BAFFLES IN PLACE LEACHFI ELD RUNBACK FLOODED OTHER (EXPLAIN) SYSTEM PUMPED BY: Bateson Enterprises, Inc. COMMENTS: CONTENTS TRANSFERRED TO: r, L' 3 h . TOWN OF NORTH ANDOVER SYSTEM PUMPING RECORD DATE: S - Z7 - 61 0 Po yvi q� 7 fa(clluwt ST . SYSTEM LOCATION (example: left front of house) rk'� �' fuse .l DATE OF PUMPING: -2 7-0 QUANTITY PUMPED—7 SZ) GALLONS CESSPOOL: NO J YES 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:_� , TOWN OF AV SYSTEM PUMPING RECO RECEIVED DATE:] _ �1 "�} AUG 17 2004 TOWN OF NORTH ANDOVER HEALTH DEPAR__ TMENT SYSTEM OWNER & ADDRESS G.vL t' Gc,✓L� aol u,vvL-- SYSTEM LOCATION (example: left front of house) back n� DATE OF PUMPING: _ Oq QUANTITY PUMPED: _ Q -Z:) GAL NS 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: CONTENTS TRANSFERRED TO: G.L.S.D V Lowell Waste 4"\, Commonwealth of Massachusetts City/Town of \J - System Pumping Record . - Form 4 OCT - 9 2063 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 rh6k be submitted to the local Board of Health or other approving authority. Important: When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. A. Facility Information 1. SysteALocatio. n: Address Cityfrown 2. System Owner. Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): Kou'-Se. State Zip Code State/ /� R � � p Code Telephone Number q -D3 -c Fs Date 2. Quantity Pumped: Gallons Cesspool(s) Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: W -t) 6. Syste P ped By: M Vu Name 7. t5form4.doc• 06/03 Company content re disposed: Vehicle License Number System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts- Citylfown of R IVED System Pumping Record JUN 3 0 2010 Form 4 M TOWN OF NORTH ANDOVER DEP has provided this form for use by local Boards of Health. Ot! I a HE8i!MM49TM'UjUujthe information must be. substantially the same as that provided here. Before using this form, check with your local Board of Health tQ determine the form they use. The System Pumping Record must be submitted to the local Board of Health opoth r approving authority. A. Facility Information 1. System Location: Left side of house, Right side of house, Left front of house, Right front of house, Left rear of houseCRlgfi't rear of house - eft rear of building. Right rear of building. Address Cityrrown State 2. System Owner: Name Address (if different from location) Cityrrown Zip Code State i Zip Code Telephone Number B. Pumping Record io— � 1. Date of Pumping y 2Quantity Date . uanty Pumped: Gallons 3. Type of system: ElCesspool(s) Septic Tank E]Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No If es, was it cleaned? Yes No Y ❑ ❑ 5. Condition of System: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Location where contents were disposed: G.L.S Lowell Waste Water Signature of Hauler F5821 Vehicle License Number 0 c 2 )L Date t5form4.doc• 06/03 System Pumping Recons • Page 1 of 1 Commonwealth of Massachusetts lugCity/Town of System Pumping Record Form 4 t5form4.doc• 06103 I VD -1 oil AUG 0 6 2012 TOWN OF NORTH ANDOVER HEALTH DEPARTMENT DEP has provided this form'for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use. The System Pumping Record must be submitted to the local Board of Health or other approving authority. A. Facility Information 1. System Location: Left/ Right front of house, Left i h re , Left/ right side of house, Left/ Right side of building, Left / Right front of building, Left / Right rear of building, Under deck Address 1 ' q(0� c,�v� o City/Town State 2. System Owner. �i.✓1 X10 Vo Name Address (if different from location) Cityrrown Zip Code State Zip Code Telephone Number B. Pumping Record 1. Date of Pumping � 2 uantity Pumped Date 3. Type of system:❑ Cesspool(s) Septic Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes 5. Condition of System: 6. S�%tem Pum* By: Neil Bateson ly©c7 Gallons ❑ Tight Tank No If yes, was it cleaned? ❑ Yes ❑ No Name Bateson Enterprises Inc Company 7. Location ere contents were disposed: G.L S. Lowell Waste Water F5821 Vehicle License Number - ,P- —LQ— Date System Pumping Record • Page 1 of 1 Commonwealth of Massachusetts _ City/Town of w' System Pumping Record y` Form 4 DEP has provided this form for usei 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 / Right front of house, Le �iggt Left / right side of house, Left / Right side of building, Left / Right front of building, uilding, Under deck Andress /1� City/rown ` v State 2. System Owner. Name Address (if different from location) Citylrown B. Pumping Record 1. Date of Pumping Date G 1aYA e Zip Code state Zip Code f L(3 Telephone Number 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) p is Tank ❑ Tight Tank ❑ Other (describe): 4. Effluent Tee Filter present? ❑ Yes No Ifes was it cleaned? Y � El Yes ❑ No 5. Conditio f stem: 6. System Pumped By: Neil Bateson Name Bateson Enterprises Inc Company 7. Locatio re contents were disposed: GLS. Lowell Waste W. 6 F5821 r nEr. 17 2012 Vehicle License Number TOWN OF NORTH ANDOVER HEALTH DEPARTMENT Ca —I(— c a Date t5form4.doc• 06/03 System Pumping Record • Page 1 of 1