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HomeMy WebLinkAboutTitle V Inspection Report - 76 GRANVILLE LANE 6/28/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form RECEIVED Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address OF No "T�P'NUUVV-V" TP Thomas NoleftOWN e LlH L)EPARIM04'T Ow er Owner's Name inforire.d for every mation is req North Andover MA 01845 6-19-2018 � pag City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any IM ortant: way. Please see completeness checklist at the end of the form. fillip ut forms When A. General Information n t e computer, use only the tab 1. Inspector: key to move your cur,,or-do not Neil James Bateson use the return Name of Inspector key Bateson Enterprises Inc. Company Name 111 Arqilla Road ------------------- Company Address AndoverMA 01810 City/Town State Zip Code 978-476-4786 SI-15 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5 (310 CMR 16.000).The system: Passes ❑ Conditionally Passes E] Fails Ej Needs Fpj1her Evaluation by the Local Approving Authority 6-19-2018 Insp t OsS nature Date The system inspector shall submit a copy of this inspection report to the Approving Authority (Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ""This report only describes conditions at the time of inspection and under the conditions of use at that time.This Inspection does not address how the system will perform in the future under the same or different conditions of use. t5ir s.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Owner Owner's Name -info-mation is req fired for every North Andover MA 01845 6-19-2018 pag City/Town State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section D A) System Passes: 1 have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: ---------- B) System Conditionally Passes: ❑ one or more-system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): 15111 s.dor rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposaf System-Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Owner (7wner's Name info 7 tion is req ired for every North Andover MA 01845 6-19-2018 Pag Cityrrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont,): F-1 Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): [I broken pipe(s) are replaced M Y Fj N [:1 ND (Explain below): ❑ obstruction is removed El Y [I N n ND (Explain below): ❑ distribution box is leveled or replaced El Y [:1 N n ND (Explain below): ----------------------- ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced El Y 0 N n ND (Explain below): ❑ obstruction is removed F1 Y El N n ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: n Cesspool or privy is within 50 feet of a surface water El Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t51s.doc rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pqge 3 of 17 Commonweatth of,Massachusetts -- _____T- -- -- - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Ow r er Owner's Name -information is reqUired for every North Andover MA 01845 6-19-2018 pag,. CityfTown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, If any) determines that the system is functioning in a manner that,protects the public health., safety and environment: E] 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. F The system has a septic tank and SAS and the SAS is within a Zone I of a public water supply. F-1 The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria.Applicable toAll Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No Backup of sewage into facility or system component due to overloaded or El 0 clogged SAS or cesspool Discharge or ponding of effluent to the surface of the ground or surface waters El 0 due to an overloaded or clogged SAS or cesspool Static liquid level in the distribution box above outlet invert due to an overloaded El 0 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. t5i7oc-rev.6116 Title 5 official Inspection Forms Subsurface sewage Disposal System-Papa 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Ow er Owner's Name infoI tion is North Andover MA 01845 6-19-2018 reqL 11 for every page. City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No El 2 Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: El Any portion of the SAS, cesspool or privy is below high ground water eleyation. Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. El 0 Any portion of a cesspool or privy is within a Zone 1 of a public well. El H Any portion of a cesspool or privy is within 50 feet of a private water supply well. D ED Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certifipd laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] El 0 The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000gpd. The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15,303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 16,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No El El the system is within 400 feet of a surface drinking water supply n El the system is within 200 feet of a tributary to a surface drinking water supply El F 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 If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered "yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304.The system owner should contact the appropriate regional office of the Department. II 15l s.doc rev,6116 Title 6 official Inspection Form:Subsurface Sewage Disposal System-P9ge 5 of 17 - Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments ----- 76 Granville Lane Property Address Thomas Nolette OwnerOwner's Name info mation is North Andover MA 01845 6-19-2018 req t ired for every ------- pag B. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No H El Pumping information was provided by the owner, occupant, or Board of Health R N Were any of the system components pumped out in the previous two weeks? M 0 Has the system received normal flows in the previous two week period? EJ E Have large volumes of water been introduced to the system recently or as part of this inspection? Z El Were as built plans of the system obtained and examined? (if they were not available note as N/A) 0 E] Was the facility or dwelling inspected for signs of sewage back up? 0 El Was the site inspected for signs of break out? Were all system components, excluding the SAS, located on site? Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal sy§tems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: Z E] Existing information. For example, a plan at the Board of Health. Z ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow conditions: 3 3 Number of bedrooms (design): -- Number of bedrooms (actual): DESIGN flow based on 310 CMR 15.203 (for example: I 10 gpd x#of bedrooms): 450 t5h s.doc-rev.6/16 Title 5 Official Inspection Form:subsurface sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Owher Owner's Name Infoiation is MA 01845 6-19-2018 req ired for every North Andover ...... Dag ag Cityrrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Does residence have a garbage grinder? Q Yes No Is laundry on a separate sewage system? (Include laundry system inspection El Yes 0 No information in this report.) Laundry system inspected? El Yes El No Seasonal use? n Yes [D No Water meter readings, if available(last 2 years usage (gpd)): Yes Detail: Sump pump? El Yes [D No Current Last date of occupancy: Date Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): _diHo­ns per day(g Basis of design flow (seats/persons/sq.ft., etc.): Grease trap present? F] Yes [I No Industrial waste holding tank present? n Yes n No Non-sanitary waste discharged to the Title 5 system? FI Yes 0 No Water meter readings, if available: 16lr s.doo-rev.8116 Title 5 Official Inspection Form;Subsurface Sewage Disposal system-Pjgo 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane j -- Property Address Thomas Nolefte Owner Owner's Name info rriation is req L ired for every North Andover MA 01845 619-2018 page. Cit mown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Pumped Jun 2017, owner ------- Was system pumped as part of the inspection? Yes R No If yes, volume pumped: gallons s How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees. Type of System: Septic tank, distribution box, soil absorption system F1 Single cesspool Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the IIA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t51r s.doc-rev.6/16 Title 5 Official inspection Form:Subsurface Sewage Disposal Systerr,•P19a 6 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane ------------ Property Address Thomas Nolette Owner Owners Name information is North Andover MA 01845 6-19-2018 req L fired for every pag"', City/Town State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Leach pits 36 years old. Septic tank was replaced in 2006. D-box was replaced in 2011. Info at B.O.H. ----------- Were sewage odors detected when arriving at the site? [J Yes M No Building Sewer(locate on site plan): 3 Depth below grade: feet Material of construction: H cast iron M 40 PVC F-1 other(explain): Distance from private water supply well or suction line: Comments (on condition of joints, venting, evidence of leakage, etc.): 4' Cast iron through wall, 3" PVC in house, no leaks visible. Septic Tank(locate on site plan): 2 Depth below grade: -fe—et Material of construction: concrete ❑ metal ❑ fiberglass F-1 polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) El Yes EJ No 10' x 5' x 4' Dimensions: 31' Sludge depth: 15ir s,doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pq.go 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Owner Owners Name info . -d is . -d for every North Andover MA 01845 6-19-2018----""---- require pag a, City/Town State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 30" Scum thickness 311 811 Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle 1211 How were dimensions determined? Tape Measure ------ Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Inlet tee ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Inlet cover has riser 8"deep. Pumped septic tank. —---------- Grease Trap (locate on site plan): Depth below grade: Material of construction: ❑ concrete F-1 metal n fiberglass n polyethylene E] 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: -15-a—te t5ils.doe-rev.8116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pala 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 5 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane 'Property Address Thomas Nolette Ow er Owner's Name info,mation is North Andover MA 01845 6-19-2018 req fired for every —-------–------- pag City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: n concrete El metal El fiberglass ❑ polyethylene E] other(explain): Dimensions: Capacity: —--------- Design Flow: gallons per day Alarm present: F] Yes n No Alarm level: Alarm in working order: El Yes F1 No Date of last pumping: Comments(condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). is copy attached? ❑ Yes ❑ No t5ir s.doo-rev.6116 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 <f Commonwealth of Massachusetts Title 5 Official Inspection Form mm Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette w er Owner's Name info ation is re, red for every North Andover ------- MA 01845 6-19-2018 pag Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0 Comments (note if box is level and distribution to outlets equal, any evidence of solids carryovpr, any evidence of leakage into or out of box, etc.): D-box level &distribution equal. No evidence of leakage. Light carryover, pumped d-box to clepn. Pump Chamber(locate on site plan): Pumps in working order: F-1 Yes ❑ No* Alarms in working order: 0 Yes ❑ No* Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.): If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ir s.doc-rev,6116 jitle 5 offidal inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Ow er Owner's Name info-mation is North Andover MA 01845 6-19-2018 required for every -------- pag a. City/Town State Zip Code Date of Inspection D. System Information (cont.) Type: 0 leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: El leaching fields number, dimensions: F-1 overflow cesspool number: El innovative/alternative system Type/name of technology: —------ Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): Soil ok. Vegetaion ok. No sign of ponding to surface. Camera inside of pits through outlets in d-box, no liquid to inverts Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes R No t5l s.doc-rev.6116 Titte 5 official inspection Form:Subsurface Sewage Disposal System-Page 13 of 17 <C Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolette Ow ter Owner's Name info Tnation is reqUired for every North Andover MA 01845 6-19-2018 pag Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): —-——-------- ---------- Privy (locate on site plan): Materials of construction: Dimensions —----- Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): ---- -------- t5l 5,doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property Address Thomas Nolefte Ow er Owner's Name infomation is 6-19-2018 re1red for every North Andover MA 01845 —------------ page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet, Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below F-1 drawing attached separately A r `fid to DAPcrr- 3 c, et�,v (61f s,doo-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane —__....---.._---- Property —-------- Property Address Thomas Nolette Ow i er Owners Name information is required red for every North Andover MA 01845 6-19-2018 pag Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: Z Check Slope Z Surface water Z Check cellar Z Shallow wells 4 Estimated depth to high ground water., feet -------- Please indicate all methods used to determine the high ground water elevation: Obtained from system design plans on record 6-4-19 If checked, date of design plan reviewed. Date 82 ❑ Observed site (abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health -explain: [design plan ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: As per test pits on design plan. Before filing this Inspection Report, please see Report Completeness Checklist on next page. IN s,doc-rev.6116 Title 5 Official Inspection Form:Subsurface sewage Disposal system-Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 76 Granville Lane Property7 Address Thomas Nolette Owner Owner's Name infomation is req iced for every North Andover MA 01845 6-19-2018 pag CitylTown State Zip Code Date of Inspection E. Report Completeness Checklist E inspection Summary: A, B, C, D, or E checked E inspection Summary D (System Failure Criteria Applicable to All Systems)completed 0 System Information—Estimated depth to high groundwater E Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file t5is.doc•rev.6/16 Title 5 Offidal inspection Form:Subsurface Sewage Disposal System-Page 17 of'17 l Town of North Andover Tax Map # 210-106.0-0070-0000.0 Parcel Id 17705 76 GRANVILLE LANE NOLETTE, THOMAS, J. Since Jan 2016 76 GRANVILLE LANE NORTH ANDOVER, MA 01846 Clas 101 Single Family Property Type 1 Residential Zen! 2 1 Residential Zoning3 1 Residential Size tal 1,11 Acres FY 70 2018 UB Mailina Index Nam /Address Type Loan Number Activelinact. From Until TO N`OLETTE Owner 76 �ANVILLE LANE NORTH ANDOVER MA 01845 MELKU MAKONNEN Previous Customer Inactive 5/21/2015 103"i SICK MEADOW LANE SICK ERVILLE,NJ 08081 UB Account maint. Account No Cycle Occupant Name Activelinactive Bldg d. 17395.0-76 GRANVILLE LANE Last Billing Date 4110/2018 3170,65 03 Cycle 03 Active UB ,Services Maint. Account No.3170065 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 0.63518 7.82 WTR WATER 01 ALL METER SIZE 45.60 UB eter Maintenance Accont No.3170065 SerialNo Status Location Brand Type Size YTD Cons 3643 711 a Active ERT HH b Badger w Water 0,630.63 718 pate Reading Code Consumption Posted Date Variance �/6/2018 728 a Actual 12 4/23/2018 15% 12/6/2017 716 a Actual 10 1/25/2018 -6% 111/2017 706 a Actual 12 10/18/2017 -12% /6/2017 694 a Actual 13 7/25/2017 -17% /6/2017 681 a Actual 15 4/12/2017 5% 12/8/2016 666 a Actual 15 1/23/2017 -52% �7/2016 651 a Actual 31 10/24/2016 48% 0 37% /7/2 16 620 a Actual 21 8/2/2016 /712016 599 a Actual 15 4/22/2016 -37% 12/812015 584 a Actual 24 1/20/2016 5% /8/2015 560 a Actual 23 10/16/2015 19% /8/2015 537 a Actual 4 7/24/2015 62% ' /20/2015 533 f Final Bill 10 5/20/2015 -4% /912015 523 a Actual 13 4/28/2015 1200% 2/9/2014 510 a Actual 1 1/15/2015 -48% 110/2014 509 a Actual 2 10/15/2014 -89% /9/2014 507 a Actual 18 7/16/2014 -14%21 4/1112014 -20% ,110/2014 489 a Actual 2/9/2013 468 a Actual 26 1/17/2014 40% /10/2013 442 a Actual 19 10115/2013 -6% � -/10/2013 423 a Actual 20 7/24/2013 46%� 58%/11/2013 403 a Actual 38 4/22/2013 - 12/7/2012 365 a Actual 27 10/15/2012 21%9% 22 1/9/2013 )/1212012 343 a Actual -11% 5/812012 316 a Actu a 1 20 7/16/2012 : Commonwealth of 11i assachuset s CiWTown of ;System Pumping-Record Form 4 DEP has Provided this for for use=by local Boards of Health. other form's may'be'used,but the Informationmust be substantially the same as that provided here. Before using.this form,check with your local Board of Health to determine the forrh 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 fight;rear of house eft./right side of pause, Left Right side of building, Left!Right front of building, e g rear of building, Under deck Address 6_0vw��K e �...:..C�. a .- 577rown State Zip Code 2. system owner. Name' Address(if different from location) Ci own Zi Code • �, Stater p Telephone Number r , .B. Pumping Rpeord I. Gate of Pumping Cate 2. Quantity pumped: Gallons Y---- 3. Type-Of system: ElCesspool(s) 016eptic Tank F1 Tight Tank i. ❑ other(describe): 4. Effluent Tee Filter present? ❑ Yes algo If yes, was it cleaned? ❑ Yes ❑ No, 5. Condition of System: 6; System Pumped By: Nell.Bateson F5821 j Name Vehicle License Number Bateson Ehterprises Ina Company 7. Locatio here Contents-were disposed: Lowell Waste Water f Sign a Haul Date t5form4.doc•06/08 System Pumping Record Page 1 of 1 of 5. 0 4 own of North Andover ..... . HEALTH DEPARTMENT S cimu CHECK.#: Z DATE: e H/0 NAME: CONTRACTOR NAME:, Type of Permitpr License: (Check box) • Animal • Body Art Establishment • Body Art Practitioner 0 Dumpster • Food Service- • Funeral Director,, • Massage Establishment • Massage Practice • Offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool • Tobacco • Trash/Solid Waste Hauler 0 Well Construction SEPTIC 5YAems: 0 Septic-Sail Testing El Septic-Design Approval 0 Septic Disposal Works Construction(OWC) $ EJ Septic Disposal Works installers(DWI) 0 Title 5 Inspector Title 5 Report $ EJ Other. (Indicate),----- $ HealthAgent Initials White®Applicant Yellow-Health Pink-Treasurer