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HomeMy WebLinkAboutTitle V Inspection Report - 21 ASH STREET 7/31/2018 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments Im 21 Ash Street - Property Address Robin Colombosian ower er Owners Name info n ation is req red for every North Andover MA 01845 7-24-2018 pa#i City/Town State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Imprtant:When fillino�out forms A. General Information fl on the computer, use'only the tab 1, Inspector: key�o move your cursor-do not N�1,Wk�'0�'5 C� use�he return Neil J. Bateson %'4 key. Name of Inspector Bateson Enterprises Inc. 11 dh Company Name -- 111 Argilla Road Company Address Andover MA 01810 CityfTown State Zip Code 978475-4786 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 16.340 of Title 5 (310 CMR 15.000).The system: D Passes Conditionally Passes ❑ Fails El Needs Turther Evaluati by the Local Approving Authority 7-24-2018 Ins p646ej8ignature(_,-� 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 DER 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. t5in�.cloc-rev.6116 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 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is req red for every p a North Andover MA 01845 7-24-2018 I City/Town State Zip Code Date of Inspection 91. B. Certification (cont.) Inspection Summary: Check A,B,C,D or E always complete all of Section D A) System Passes: I 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: 13) 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): ........... t6in�.d..-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Ower Owner's Name info i ation is MA 01845 7-24-2018 req red for every North Andover - 7 pag6- City/Town State Zip Code Date of Inspection B. Certification (cont.) Fj Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. 1B) System Conditionally Passes (cont.): ❑ 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): broken pipe(s) are replaced n Y F-1 N F] ND (Explain below): ❑ obstruction is removed El Y El N El ND (Explain below): distribution box is leveled or replaced 0 Y Ej N El ND (Explain below): F-1 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 R Y ❑ N F-1 ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N r-1 ND (Explain below): C) Further Evaluation is Required by the Board of Health: F-1 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: F] Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ln5.doc-rev.8116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Ow fo;er Owners Name in 'ation is required for every North Andover MA 01845 7-24-2018 PaOl City/Town 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: El 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-1 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. El 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 to All 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 clogged SAS or cesspool 0 E 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 %day flow t6los,doc-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Ow r Owner's Name i info ation s North Andover MA 01845 7-24-2018 re ired for every p req City/Town State Zip Code Date of Inspection B. Certification (cont.) Yes No Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: _. F] E Any portion of the SAS, cesspool or privy is below high ground water elevation. El E Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. EJ E Any portion of a cesspool or privy is within a Zone 1 of a public well. EJ E Any portion of a cesspool or privy is within 50 feet of a private water supply well. EJ 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 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 and chain of custody must be attached to this form.] The system is a cesspool serving a facility with a design flow of 2000gpd- 1 0,000g pd. EJ ED 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 For or"no"to each of the following, in addition to the questions in Section D. Yes No 0 0 the system is within 400 feet of a surface drinking water supply 0 0 the system is within 200 feet of a tributary to a surface drinking water supply El El 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 16.304.The system owner should contact the appropriate regional office of the Department. t5in�,doc-rev.6116 Title 5 official inspection Form:Subsurface Sewage Disposal System-Page 5 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian OwerOwner's Name information tion is requ red for every North Andover MA 01845 7-24-2018 pag;. -dityfrown 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 Pumping information was provided by the owner, occupant, or Board of Health FJ 0 Were any of the system components pumped out in the previous two weeks? E EJ Has the system received normal flows in the previous two week period? El E Have large volumes of water been introduced to the system recently or as part of this inspection? El 0 Were as built plans of the system obtained and examined? (if they were not available note as N/A) Was the facility or dwelling inspected for signs of sewage back up? M El Was the site inspected for signs of break out? E 0 Were all system components, excluding the SAS, located on site? M El 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 E El information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: 11 Z Existing information. For example, a plan at the Board of Health. ❑ 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: Number of bedrooms (design): N/A Number of bedrooms (actual): 3 DESIGN flow based on 310 CMR 15.203 (for example'. 110 gpd x#of bedrooms): N/A 15in i.cloc,•rev,6116 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 21 Ash Street Property Address Robin Colombosian Owrer Owner's Name information is required for every North Andover MA 01845 7-24-2018 pag . Cityrrown State Zip Code Date of Inspection D. System Information Description: ------------- ---------- ------- Number of current residents: Does residence have a garbage grinder? El Yes 0 No Is laundry on a separate sewage system? (Include laundry system inspection El Yes E No information in this report.) Laundry system inspected? r_1 Yes E] No Seasonal use? El Yes 0 No Yes Water meter readings, if available(last 2 years usage (gpd)): 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): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? El Yes 0 No Industrial waste holding tank present? El Yes Ej No Non-sanitary waste discharged to the Title 5 system? El Yes El No Water meter readings, if available: t5ins.doc-rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian ------------- Owerme info ation is Owner's Nallorth Andover MA 01845 7-24-2018 required for every page City/Town 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 last year, owner Was system pumped as part of the inspection? Yes ❑ No If yes, volume pumped: 1600gallons How was quantity pumped determined? Measured tank Inspect tank, baffle &tee Reason for pumping: Type of System: Septic tank, distribution box, soil absorption system Single cesspool Overflow cesspool 0 Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) 0 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 UA system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. El Other(describe): t5insAoc-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Of Owner's Name info;eration is required for every North Andover ------- ----------- --------------- MA 01845 7-24-2018 pag;. CityTrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: House built 1982, owner Were sewage odors detected when arriving at the site? ❑ Yes No Building Sewer(locate on site plan): Depth below grade: 1.8 feet Material of construction: n cast iron El 40 PVC El other(explain): Distance from private water supply well or suction line: -feet ------- Comments (on condition of joints, venting, evidence of leakage, etc.): Finished cellar, unable to see piping leaving foundation. Septic Tank(locate on site plan): 0.8 Depth below grade: feet Material of construction: concrete ❑ metal 0 fiberglass 0 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 [I No Dimensions: 211 Sludge depth: t5in§.doc-rev.6/16 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is req ired for every North Andover MA 01845 7-24-2018 pZ. City/Town State Zip Code — da—tWR—Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 3111 21 Scum thickness 811 Distance from top of scum to top of outlet tee or baffle --------- 13" Distance from bottom of scum to bottom of outlet tee or baffle Now 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 baffle ok. Outlet tee ok, Depth of liquid at outlet invert. No evidence of leakage. Depth of liquid at outlet invert. Pumped septic tank ---------- Grease Trap (locate on site plan): Depth below grade: feet Material of construction: F-1 concrete 0 metal ❑fiberglass F-1 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: t5ins.dDc-rev.6/16 Title 6 Official Inspection Form:Subsurface Sewage Disposal SYst8m•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Ow Owner's Name in o7mation is red for every North Andover MA 01845 7-24-2018 req CityfTown State Zip Code Date of Inspection I pag 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: F1 concrete F-1 metal n fiberglass F-1 polyethylene El other(explain): ----------- Dimensions: ------ Capacity: gallons _ _ Design Flow: gallons per day Alarm present: El Yes E-1 No Alarm level: Alarm in working order: E-1 Yes F-1 No Date of last pumping: tate ___._ _ _._..._-- __.._ Comments bii e- Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No Krmcl..-rev.6116 Title 5 Official Inspection Form:Subsurface sewage oisposal system•Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian ow er Owner's Name i fo; r la n r tion is requIred for every North Andover MA 01845 7-24-2018 page. CityfTown 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 -1/211 ----------- Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal. Liquid level in d-box below all inverts, evidence of leakage. D-box has corrosion holes, needs to be replaced. D-box 3' deep, needs riser installed on d-box. Pump Chamber(locate on site plan): Pumps in working order: F❑-1Yes F] Na* Alarms in working order: R Yes F-1 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: illin"Idoc-rev.6116 Title 5 Official 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 21 Ash Street Property Address Robin Colombosian Ow er Owner's Name info ation i's ort req fired for every North Andover MA 01845 7-24-2018 pag CitylTown State Zip Code Date of Inspection D. System Information (cont.) Type: El leaching pits number: F leaching chambers number: ❑ leaching galleries number: leaching trenches number, length: 4 trenches 40' long El leaching fields number, dimensions: ❑ overflow cesspool number: ❑ 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,Vegetation ok. No sign of ponding to surface. ---------- 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 0 No t5ins:Ace-rev.6116 Title 5 Official inspection Form:Subsurface Sewage Disposal System-page 13 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Owner Owner's Name information is reqqired for every North Andover MA 01845 7-24-2018 Page. 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,): -—-—------------ III .............. ------------ t5in:doe-rev.6/16 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form x Subsurface Sewage Disposal System Form Not for Voluntary Assessments -_------ 21 Ash Street Property Address Robin Colombosian Owr er Owners Name info r lation is N -24-2018 reqj ired for every North Andover MA 01845 7 pag . 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: Z hand-sketch in the area below El drawing attached separately 6 wafe�- t-6vse_ cf D, -9C* ri I OL13- i r 15ina.doc 3- t5ins:.doc rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 15 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form 5-3 Subsurface Sewage Disposal System Form Not for Voluntary Assessments 21 Ash Street Property Address Robin Colombosian Ow er Owners Name infer is requ�red for every North Andover MA 01845 7-24-2018 pag Cityfrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: M Check Slope Surface water Check cellar Shallow wells >4 Estimated depth to high ground water: feet Please indicate all methods used to determine the high ground water elevation: D Obtained from system design plans on record If checked, date of design plan reviewed: ❑ Observed site(abutting property/observation hole within 150 feet of SAS) D Checked with local Board of Health-explain: ❑ Checked with local excavators, installers-(attach documentation) Accessed USGS database-explain: Essex County Soil Map ——--------- You must describe how you established the high ground water elevation: Essex County Soil Map, Sheet#36, Canton Soil, Water> Udeep. Before filing this Inspection Report, please see Report Completeness Checklist on next page. l5tn�.doc•rev.6716 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 21 Ash Street Property Address Robin Colombosian ow er Owner's Name info motion is q red for every North Andover MA 01845 7-24-2018 Pgl�i City/Town State Zip Code Dateofinspection E. Report Completeness Checklist E Inspection Summary: A, B, C, D, or E checked Inspection Summary D (System Failure Criteria Applicable to All Systems)completed System Information—Estimated depth to high groundwater Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file II t5ins.doc•rev.6116 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Town of North Andover Tax Map # 210-106.D-0041-0000.0 Parcel Id 17801 21 ASH STREET COUYOUMJIAN, ROBIN 21 ASH ST NORTH ANDOVER, MA 01845 ----—------------------ Class 101 Single Family Property Type I Residential Zonin 2 1 Residential Zoning3 I Residential Size T ta 1 1.22 Acres FY 2018 UB Mailing Index Name ddress Type Loan Number Active/Inact. From Until COUY I UMJIAN, ROBIN Payor 21 ASH ST NORTH ANDOVER, MA 01845 UB Account Maint. Account No Cycle Occupant Name Active/inactive Bldg Id. 17927.0-21 ASH STREET Last Billing Date 4/10/2018 31705?5 03 Cycle 03 Active I UB Services Maint. Account No.3170595 Service Code Rate Charge Multiplier/Users MISCFEE ADMIN FEE 1 1 9.18 WTR WATER 01 ALL METER SIZE 45.60 UB Meter Maintenance Accou�it No.3170595 Serial o Status Location Brand Type Size YTD Cons 17264 80 a Active ERT HH METE METE w Water 1 1 601 D to Reading Code Consumption Posted Date Variance 6,8/2018 916 a Actual 12 -4% 36/2018 904 a Actual 12 4/23/2018 70% 1116/2017 1 892 a Actual 7 1/25/2018 -47% 9w2017 885 a Actual 14 10/18/2017 4% 66/2017 871 a Actual 13 7/25/2017 -3% 3'7/2017 858 a Actual 13 4/12/2017 13% 1'/9/2016 19/2016 845 a Actual 12 1/23/2017 -20% 9w2016 833 a Actual 15 10/24/2016 -5% 68/2016 818 a Actual 16 8/2/2016 -4% t/2016 802 a Actual 16 4/22/2016 10% R'1 ,19/2015 786 a Actual 15 1/20/2016 -7% 3/2015 771 a Actual 16 10/16/2015 -6% 69/2015 755 a Actual 17 7/2412015 -7% 3'l 012015 738 a Actual 18 4/28/2015 5% 1'/10/2014 720 a Actual 17 1/15/2015 6% 9 12/2014 703 a Actual 17 10/15/2014 -10% 610/2014 686 a Actual 18 7/16/2014 9% 312/2014 668 a Actual 17 4/11/2014 10% 12/912013 651 a Actual 15 1/17/2014 0% 11 0/2013 636 a Actual 15 10/15/2013 2% 61212013 621 a Actual 15 7124/2013 -6% 3 12/2013 606 a Actual 16 4/22/2013 1% 11 Y10/2012 590 a Actual 15 1/9/2013 23% 914/2012 575 a Actual 13 10/15/2012 -10% 13/2012 562 a Actual 14 7/16/2012 3% 315/2012 548 a Actual 14 4/14/2012 -20% 1113/2011 534 a Actuat 17 1/17/2012 32% �14/20111 517 a Actual 14 10/13/2011 8% 96812011 503 a Actual 12 7/20/2011 -10% i :. , Commonwealth of Massachusetts City/Town of . System P•umpin§.Record Form 4 DEP has provided this form for use-by local Boards of,Health.Other form's may bsed,but the Information'must be substantially the carne 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�o the local Board of Health or other approving authority. A. Facility Information 1. System Location: Loft/Right front of Mouse, Left/Right rear of housa, Left/right side of house, Left t Right side of building, Left I Right front of buildirig, Left/Right rear cif building, Under deck Address City/Town state zip Code 2. System Owner. Name' Address(if different from location) City/Town ' State- Zip Code Telephone Number r t B. Pumping Record 1. Date of Pumping cyte hty Pumped: Gallons . � r 3. Type of system: [ Cesspool(s) ;I�eprlucara, nk ❑ Tight Tank 1 ® Other(describe): 4. Effluent Tee Filter present? ❑ Yes 040 if yes, was it cleaned? ❑ Yes ❑ No, 'S. Condition of System: 6. System Pumped By. Nell.Bateson ' F5821 Name Vehicle License Number Bateson Enterprises Ina Company 7. L contents-were disposed: +C S Lowell Waste Water signAtufa cf HaulwU Date 15farm4.do(,-06103 System Pumping Record•page 1 of 1 Town qfNorth Andover HEALTH DEPARTMENT US I I DATE: LOCATION: H/0 NAME: L-111LI-Ijin"�� f CONTRACTOR NAME: Type of Permit or License:(Check box) 0 Animal El Body Art Establishment 0 Body Art Practitioner D Dumpster 0 Food Service- s- 0 Funeral Directors $- 0 Massage.Establishinent $ 0 Massage Practice $ 0 Offal(Septic)Hauler 0 Recreational Camp 0 Sun tanning 0 Swimming Pool $ 0 Tobacco 0 Trash/Solid Waste Hauler $ 0 Well Construction $ SEPTIC Systems: 0 Septic-Soil Testing 0 Septic-Design Approval $ 0 Septic Disposal Works construction(DWQ $- 0 Septic Disposal Works Installers(DWI) $ 0 Title 5 Inspector Title 5 Report $ 0 Other:(Indicate)--___ Health Agent Initials White-Applicant Yellow-Health Pink-Treasurer