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REPORT OF PERC TEST
NORTH ANDOVER BOARD OF HEALTh,
ADDRESS OF SYSTE 4I 0/ 46 / r2Z22e2 V,"114 Z C4-,_7 e
NAME OF PROFESSIONAL ENGI Fit OR SANITARIAN CONDUCTING TESTS
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NAME OF LOT OWNER �P(J, �" • ADDRESS /erg Y4-1.
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SHOW APPROMATE LOCATION OF PITS ON SKETCH ON REAR OF THIS SHEET
Soil Log T s/oil : Subsoil _ D
ja(�o-./ Llon_
Pere Tests Depth
Saturation Time
the &
Time to
Dr OU 12t' - 911
Total
Water Level Pit DEpth
/ - 71'/ b
Time to
Droo 9" - 6t'
Other Con siderations:a!�L iA/lJ • -/1/✓ 19E' 11,/0-0-74
Recommendations: Ln �E'✓ Z/1
Signature
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APPROVED DISAPPROVED
Date: Date: —14:--1 - -7
1.11-1- , �� Reason:
1. As Built Wmitted
*IORTH kNDOVIR BO_ARD OF HKAJ,711
IIi5Ti1T.I,A TOIv CHECK LIST.
I?--/ T-7% EXCAVA T ION OK',
1
Lot location, dimensions, of system, location in regard to
percolation tests, depth of system, grater table
2. Distance to I-Ietland Areas, Drains, Street & House, Drainage Easement and Wells.
3. Water ine Location
4. No P Pipe
5. Sep" c Tank - Tees, Cement --Pipe to Tank -Joints on both side of Tank.
6. Distribution Box - No cracks i ox or co er, all lines flow equally from box.
7. Leach Fields - Dimee-Icns, Stone epths, Cappe ends, Clean dou�7-i.raslhed stone
8. Leach Pits - Dimensions, Depth of Stone, Splash pard tees, Cement -pipe to tank -
joints on both sides of tank-, Clean double-umashed stone
9. No Garbage Disposals
10. Final Grading k'barricading of sub -surface system)
TO: NORTH ANDOVER, MASS -2)E C 6 19 %17
BOARD OF HEALTH
FROM: DESIGN ENGINEER Re: Soil Absorption Sewage
System Inspection
This is to certify that I have inspected the construction of the said disposal system at
1—G % 74 CX 4/V V /1//,i North Andover, Mass.
SITE LOCATION
The grades and construction are as specified in my plans and specifications dated
19 .
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`TOWN :OF NORTH ANDOVER
SYSTEM PUMPING RECORD
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OWNER &ADDRESS SYSTEM LOCATION
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P�TMPING 5 �..
Of
QUANTITY PUMPED GALLONS
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,,, GOOD CONDITION
HEAVY GREASE FULL TO COVER
BAFFLES IN PLACE
f <' ROOTS
- : LEACHFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER .._. .OTHER (EXPLAIN)
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Commonwealth of Massachusetts RSU ��
City/Town of North Andover
System Pumping Record OCT a 201
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 within 14 days from the pumping date in
accordance with 310 CMR 15.351. ;
A. Facility Information
MUUIC55
north andover '- Ma -
City/Town State Zip Code
2. System Owner.-
Name
wner:
Name
Address (if different from location)
north andover
City/Town
State
Telephone Number
Zip Code
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Q:k Septic Tank ❑ Tight Tank ❑ Grease Trap
❑ Other (describe):
4. Effluent Tee Filter present? ❑ Yes fT'No If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6. System Pumped By:
7
Name Vehicle License Number
Stewart's Septic Service
Company
Location where contents were disposed:
Stewart's Pre-treatment Plant, 20 So. Mill Bradford, Ma 01835
Signature of Ha ler Date
Signature of ceiving Facility Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1