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HomeMy WebLinkAbout- Septic Pumping Slip - 1907 SALEM STREET 9/24/2018 (3) Commonwealth of Massachusetts Title 5 Official Inspection Form > Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street _Property Address 71 Jon He(denreich Owner Owners Name information is required for every North Andover MA 01845 9-20-2018 page. 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. Important:When A. Inspector Information filling out forms on the computer, use only the tab Neil James Bateson key to move your Name of Inspector cursor-do not Bateson Enterprises Inc. use the return key. Company Name 111-,"Ila Road 4-1lb Company Address-A Andover MA 01810 City/Town State Zip Code 978-475-4786 SI-15 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 16.000); 1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. Passes 2. ❑ Conditionally Passes 3. Needs Further Evaluation by the Local Approving Authority 4. 0 Fails 9-20-2018 InspectNorsSigna re- 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 form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note: 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. t5insp,doe•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 1 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1907 Salem Street Property Address Jon Heydenreich Owner Owner's Name information is North Andover MA 01845 9-20-2018 required far every page Cityfrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) 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: 2) 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): l5insp.doc rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 18 i Commonwealth of Massachusetts Title .5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street Property Address Jon He ydenreich OwnerOwner's Name information is North Andover MA 01845 9-20-2018 required for every page. City/Town State Zip Code Date of Inspection j G. Inspection Summary (cont.) 2) System Conditionally Passes (cont.): F] Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. D 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 F1 Y n N F] ND (Explain below): ❑ obstruction is removed El Y n N ❑ ND (Explain below): ❑ distribution box is leveled or replaced El Y El 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): r-1 broken pipe(s)are replaced ❑ Y F-1 N n ND(Explain below): F] obstruction is removed r-] Y F-1 N n ND (Explain below): 3) Further Evaluation is Required by the Board of Health: F] 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. a. 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: t5insp.doo-rev.7126/2018 Title 5 Offidal Inspection Form:Subsurface Sewage Disposal System-Page 3 Of 18 Commonwealth of Massachusetts 1 =: Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1907 Salem Street Property Address Jon Heydenreich Owner owner's game information is required for every North Andover MA 01845 9-20-2018 -- page. Cityrrown State Zip Code Date of Inspection 1 C. Inspection Summary (cant.) ❑ 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 b. 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: ❑ 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. 0 The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. Q 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. I c. Other: 4) 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 Discharge or ponding of effluent to the surface of the ground or surface Waters El E due to an overloaded or clogged SAS or cesspool l5insp.doc•rev.712612018 Title 5 official inspection Form:Subsurface Sewage Disposal System•Page 4 or 18 Commonwealth of Massachusetts Tide 5 Official Inspection Farm Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1 1907 Salem Street Property Address Jon Heydenreich Owner Owner's Name information is required for every North Andover MA 01845 9-20-2018 ..._.-_ -__ page. City/Town State Zip Code Date of Inspection C. Inspection Summary (cant.) 4) System Failure Criteria Applicable to All Systems: (cant.) Yes No ® 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 '/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 SAS, cesspool or privy is below high ground water elevation. ® Any portion of 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 1 of a public water supply 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. [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 2000 gpd- 10,000 gpd. ® 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. 5) 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 CA. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection El Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doo•rov.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 5 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form i Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street Property Address Jon Heydenreich Owner Owner's Name information is required for every North Andover MA 01845 9-20-2018 ............ ---------- page. tyfrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes" to any question in Section C.5 the system is considered a significant threat, or answered "yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system'owner should contact the appropriate regional office of the Department. 6. You must indicate"yes" or"no"for each of the following for all inspections: Yes No Pumping information was provided by the owner, occupant, or Board of Health ❑ Were any of the system components pumped out in the previous two weeks? El Has the system received normal flows in the previous two week period? Have large volumes of water been introduced to the system recently or as part of this inspection? 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? EJ Was the site inspected for signs of break out? M Were all system components, excluding the SAS, located on site? Z E] 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 systems? The size and location of the Soil Absorption System (SAS) on the site has been determined based on: 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 E El approximation of distance is unacceptable) [310 CMR 15.302(5)] t5msp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 18 Commonwealth of Massachusetts h == _ `title 5 Official Inspection Form y Subsurface Sewage Disposal System Form-Not for Voluntary Assessments u 1907 Salem Street Property Address Jon Heydenreich Owner Owner's Name information equire required is North Andover NIA 01845 9-20-2018 required for every ---------- - page. City/Town State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms (design): 5 - — Number of bedrooms (actual): 5 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 550 Description: 2 Number of current residents: Does residence have a garbage grinder? ❑ Yes ® No Does residence have a water treatment unit? F-1 Yes ® No If yes, discharges to; - - Is laundry on a separate sewage system? (Include laundry system inspection © Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? El Yes ® No Water meter readings, if available last 2 ears usage d Yes 9 ( Y 9 (9p ))� Detail: Sump pump? ® Yes ® No Current Last date of occupancy: -Date I i5insp.doc rev.712612g18 Trite 5 official Inspection Form:Subsurface sewage Disposal system•Page 7 of 18 Commonwealth of Massachusetts ❑a ..� Title 5 Official Inspection Form i; Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1907 Salem Street Property Address ~mm Jon He denreich .-_...._........ Owner Owner's Name information is North Andover MA 01845 9-20-2018 required far every .................................___._ .. �.._.......-..-_- page. City/Town state Zip Code Date of Inspection D. System Information (cunt.) 2. 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? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: --- Last date of occupancy/use: Data -- - Other(describe below): 3. Pumping Records: Source of information: Pumped 2016,owner Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 1500 gallons How was quantity pumped determined? Measured tank Reason for pumping: Inspect tank&tees. l5insp.doo-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 0 of 18 c Commonwealth of Massachusetts A Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1907 Salem Street Property Address Jon Heydenreich Owner ------ __ ._._..---- Owner's Name information is required for every North Andover MA 01845 9-20-2018 _ page. City[Town State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® 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) 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 I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed (if known)and source of information: 8 Years old, 12-1-2010,_as built plan Were sewage odors detected when arriving at the site? ❑ Yes ® No I 5. Building Sewer(locate on site plan): 3 _ Depth below grade: feet - -- Material of construction: ® cast iron ®40 PVC ❑ other(explain): _..._..._ Distance from private water supply well or suction line: Test- - Comments (on condition of joints, venting, evidence of leakage, etc.): 4"Cast Iron through wall 3" PVC in house, no leaks visible. i t61nsp.doe-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street JProperty Address Jon Heyqenreich ...... Owner Owners Name information is required for every North Andover MA 01845 9-20-2018 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): 0.8 Depth below grade: feet Material of construction: F-1 concrete F-1 metal El fiberglass [I polyethylene ❑ other(explain) If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) F] Yes El No 10' x 5'x 4' Dimensions: 21' Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 3111 211 Scum thickness 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 1311 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 to ok. Outlet tee ok. Depth of liquid at outlet invert. No evidence of leakage. Pumped septic tank &cleaned outlet filter. Inlet cover&outlet covers has risers to grade.. t5insp.doe-rev.712612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 10 of 18 Commonwealth of Massachusetts =f Title 5 Official Inspection Form s Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1907 Salem Street Property Address _._.. Jon Heydenreich Owner Owner's Name _. information is North Andover MA 01845 9-20-_2018 required for every _. --- page. City/Town State Zip Code Date of Inspection D. System Information (cant.) 7. Grease Trap(locate on site plan): Depth below grade: feet -.__.. 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: Date Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Y 8. Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons "- i Design Flow: gallons per day l5insp.doe•rev.712612018 Title 5 Official inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street Property Address Jon Heydenreich Owner Owner's Name information is required for every North Andover MA 01845 9-20-2018 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank (cont.) Alarm present: El Yes Fj No Alarm level: Alarm in working order: n Yes El No Date of last pumping: -bate Comments (condition of alarm and float switches, etc.): Attach copy of current pumping contract(required). Is copy attached? R Yes ❑ No 9. 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 carryover, any evidence of leakage into or out of box, etc.): D-box level &distribution equal, has flow levelers. No evidence of leakage. Evidence of light carryover, pumped d-box to clean. D-box has riser 6" deep. 15insp.doc-rev.7/2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments 1907 Salem Street Property Address Jon Heydenreich __-_ Owner Owner's Name information is North Andover MA 01845 9-20-2018 required for every -- page Cityrrown State Zip Code Date of Inspection D. System Information (cant.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ 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. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: El leaching pits number: — - I ® leaching chambers number: 55 ❑ leaching galleries number: _ ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number; ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street Property Address Jon He denreich Owner Owner's Name information is required for every North Andover MA 01845 9-20-2018 page. dityfrown State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS) (cont.) 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. 5 rows of infiltrators with 11 chambers per row. Opened up inspection port, no liquid present ........... 12, 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 M Yes ❑ No Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doo-rev.712612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street _- Property Address Jonj Hey4enreich Owner Owner's Name Information is required for every North Andover MA 01845 9-20-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 13. 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.): it t5insp.doc•rev.7/2612.018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Pago 15 Of 18 Commonwealth of Massachusetts Title 5 official Inspection Farm Subsurface Sewage Disposal System Form -Not for Voluntary Assessments 1907 Salem Street Property Address Jon Heydenreich Owner Owner's Name 18 information is every North ORo Andover -— e 01845 IpC ode Date ofInspection required for eve page. y D. System Information (cant.) 14. 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 ❑ drawing attached separately a r t'7 ptr `L( u � rUvev� 15insp.doc•rev.7/26/2018 Title 5 officiai Inspection Form:Subsurface Sewage Disposal System•Page 16 of is Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street JProperty Address Jon_-He denreich Owner Owner's Name information Is required for every North Andover MA 01845 9-20-2018 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 15. 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: z Obtained from system design plans on record If checked, date of design plan reviewed: -5—at 9-30-2010 a____ ❑ Observed site (abutting property/observation hole within 150 feet of SAS) z Checked with local Board of Health -explain: Design plap__,._ ❑ 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 pit data on design plan Before filing this Inspection Report, please see Report Completeness Checklist on next page. t51nsp.doc•rev.7/26/2018 Title 5 Official inspection Form:Subsurface Sewage Disposal System-Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form Not for Voluntary Assessments 1907 Salem Street 'Property Address Jon He denreich Owner Owner's Name information is required for every North Andover MA 01845 9-20-2018 page. CityfTown State Zip Code Date of Inspection E. Report Completeness Checklist Complete all applicable sections of this form inclusive of: A. Inspector Information: Complete all fields in this section. B. Certification: Signed & Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1, 2, 3, or 5 completed as appropriate 4 (Failure Criteria)and 6 (Checklist) completed D. System Information: For 8: Tight/Holding Tank—Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal SY816m•P890 18 Of 18 Commonwealth of Massaohusefts City/Town of . System Pumping-Record Form 4 DEP has provided this forrri for use-by local Boards of Health. Other forms may be'used,but the information-must be substantially the tame 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. F'act0ty, InforMation 1. System Location: Left I Right front of house, Left]Right rear of house, 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 Zip Code Z. System OwnerJAI Name• Address(I different from location) City/Town ` State-� Zi Cade� ; Telephone Number F ,B. Pumping Rpeord 9. Date of Pumping J62Date ¢(�Gluandty Pumped: Gallons 3. Type•of system: ❑ Cesspool(s) • B—SS-pti Tank ❑ Tight Tank i. ❑ Other(describe): 4. Effluent Tee Filter present? 6"Ves ❑ No if yes, was it cleaned? uys 0 No ' S. Condition of System' 6: system Pumped By: Nell.Bateson F6821 Name Vehicle License Number Bateson Enterprises Inc Company 7. Locatl re contents-were disposed: b S: Lowell Waste Water Sign a Houle Date I t5form4.docr 08/03 System Pumping Record•Page 1 of 1 � Summary Record Card generated onanxmoo2:m.mpmby Karen Hanlon Page Town of North Andover Tax Map # 210_1063~0012~0000,0 ' Parcel |d17427 1907 SALEO8STREET HEYDENRBCH. JONATHAN 1907 SALE0lSTREET N, ANDOVER, KOA 01845 Class 101 Single Family Property Type 1 Residential Size Total 1,06 Acres FY 2019 Type Loan Number AotivoNnuot. From Until MEYDENRE|CH,JON/THAN Payer mx/vo 1907GA[EM STREET N.ANOUVER, MA 01845 Account No Cycle Occupant Name Acu°a/|vent|vo Bldg |d. 17493.0-1SU7SALEMSTREET Last Billing Date7/18/2V1O 3170163 O%Cycle O3 Active Account No.J17Q1s3 Service Code Rate Charge Mu|dp|iedUsmns M|SCFEEADM|N FEE 1 1 9.18 1/ vVTRVvKTER 01 ALL METER SIZE 30.40 U UB Meter Maintenance Account No. 8170163 Serial No Status Location Brand Type Size YTDConn 13240299 o8ct|ve ERT HH METE METE wWa$ar 11 527 oahm Reading Code Consumption Posted Date Variance 6/8/2018 939 uActuo| 8 7/23/2010 '41% 13 4���V18 4394 o��O10 831 oA�uo| 12/6/2017 918 aAmua| 8 1/25/2018 VU% 8@12017 809 oActua| 5 10/102017 '58Y4 6/6/2017 SO4 eActua| 11 7/282017 -18Y6 3/7/2017 895 m Actual| 13 4/12/2017 24% 12/9/2016 880 aActoo| 11 1/23/2017 '796 9/8/2016 869 aActua| 12 1024/2016 '8Y6 6/7/2010 857 aActom| 13 8/2/2016 -3% 3/7/2016 844 o8ctua| 13 4/22/2016 12% 12/9/2015 831 aAutuo| 12 1/202010 0396 9m/2015 819 aAotuo| 8 1016/2015 '3296 618/2015 810 aAnma| 13 7/24/2015 696 30/2015 797 o8oma| 12 4/28/2015 O% 13/10/2014 785 uActuo| 12 1/15/2015 '8% 9/12/2014 rm mActuo| 14 1015/2014 '11% 60/2014 758 aAotum| lo 7n6/201* uY+ 3/102014 744 oActua| 15 4/11/2014 7% 12/6/2013 729 aAmua| 13 1/17/2014 24% 3/10/2013 716 oActuo| 11 10/15/2013 -21% 6/11/2013 705 oAcma| 14 7/24/2013 9% 3/1212013 691 mActua\ 13 4/22/2013 -11.N 12/102012 678 oActuo| 14 1/9/2013 36% 9/13/2012 664 eActua| 11 10/15/2012 -12% 6/11/2012 653 uAmua| 12 7/102012 -13% 3/13/2012 641 a Actual| 14 4/1412012 7^N 12/13/2011 627 aAmua| 13 1/17/2012 18% 8n4/3011 614 oxoma| 12 1083/2011 -7% 80/2011 soo aAmvo| 12 7/203011 -zum | � � Town of North Andover HEALTH DEPARTMENT CHECK 4 DATE:: LOCATION: H/O NAME: CONTRACTOR NAME: Type If Permit(qjj,,cens,e: (Check box) 13 Animal • Body Art Establishment • Body Art Practitioner • Dumpster 0 Food Service- 0 Funeral Directors • Massage Establishment • Massage Practice • offal(Septic)Hauler • Recreational Camp • Sun tanning • Swimming Pool El Tobacco 0 Trash/Solid Waste Hauler 0 Well Construction SEPTIC 5yAe—MS.' * Septic-Soil Testing * Septic-Design Approval * Septic Disposal Works construction(DW0 * Septic Disposal Works installers(DWI) * Title 5 inspector Title 5 Report Pal,,:55 $ [3 Other. (Indicate),--,.— ...................... Heaft Agent Initials1 311lLite-Applicant Yellow.-Health Pink- Treasurer