HomeMy WebLinkAboutMiscellaneous - 164 BRIDGES LANE 8/24/2015 Board of Realth BFPTIC MTEM
North An ver�Ma s. INSTALLATICK CHBCB LIST LOT'`
pvID DISAPPHQVID
AVATI OE ML
DATE
A?
ti easonst
sFAIL OK
1. Distance Tos
a. Wetlands
b. Drains
c.. Well
2. Water Line Location
3. No PVC Pipe
4. Septic Tank
a. _Tees --Length do To Clean Out Covers
b. Cement Pipe to Tank On Both Sides of Tank
5. Distribution Box
a. Covers & Box - No Cracks
b. All Lines Flowing Equal Amounts
c. No Back Flow
6. Leach Field or Trench
�+ �� a. Dimensions
b. Stone Depth
c: Capped Inds
d. Clean Double Washed Stone
7. Leach Pits
' a. Dimensions
b. Stone Depth
c. Splash Pads
d. Tees
e. Cement Pipe to Pit - Both Sides
f. Clean Double Washed Stone
8. No Garbage Disposal
9. Final Grading Inspection
10. Barricading Covered System
11. As Built Submitted
a. Lot Location
b. Dimensions of System
c. Location with Regard-to Pere Test
d. Elevations
e; Water Table
4
S
1
Roh'rd of Health
SUBSURFACE hIsTOSAL DF;S"1(,W CHECK LIT 1
LOT " B t
I lLFROY lD DATE
AP t. ✓V R lC m �.�.....,�.
"e"x"If
fC771
Title 4 FAIL CIK
Reg 2.5 submitted plan must show as a minim=l
} the lot to be sensed-area,cli merisione lot ,abu.tters
location and log deep observation hofe"S"-distance to ties
location
e stance to ties deAgncalc calculations tionssh .. g
quimd leaching area
"location and dimensions of . tem- -cluding neses°ve area
existing and proposed contours
g) location vat areas i 100' of sewage disposal system or
di 1 r�-check watlands mapping
(h) face and subsurface drains within 1001 of sedge disposal
system or di.sc er
) �ocation any drainage easements NAVAn 1001 of lugs disposal
-11,010 KJ) system or disclai.xr:er-Planning }hoard files
jp;tol;a sources of N;at.er simply within 2001 of sev go disposal a
system or disclair-ier
01000"0 cation of z proposed we-11 to S61 lot-1001 from leaching acili
o'jocation of water 1d.nes on proparty-101 from leaching facility
, a location of benclmark
garbage disposals
0"no PVC to be used. in const action
�W q) profile of system-elevations of basement., plumb., pipe,, septic tank*
distribution box inlets and outlets,, distribution field piping and
Dither elevations
mm ri d ground water elevation in area sewage disposal system
plan must be p: pared. by a professional FhgIneer or other
Professional authorized by lair to prcpare such plans
Reg 6 S�,ptic Tanks
(a) c apacit 05-150% of flow, vititer tables gees,, depth of tees.,
access, pv_-ping
b) cicanout
C) l.(I' from cellar urall or ingound s _wH_±ng pool
d) 2 51 from seam rface drains
Reg 10.2 Distribution Faxes
mope eap,carve tl zr 0.08
Reg 10.4 )
1
i
SOIL PROFILE & PERCOLATION TEST DATA �
North Andover, Mass. Street No
Loot No f
Loc�Subdiv. Plarrd _., Owner
Investigator Observer ✓
SOIL PROFILE DATES
l*.'El ev _ 2.El ev 3.El ev 4.El ev
Ties Pte s est
s
2 2 2 2
3 3 3 3
4 4 4 ` cry 4
,,-A-1011 _
_.._e. 6 ._ 6 _ 6
7 7r _. 7
8 s 8
9 _ 9 _ . 9 9
10 10 10 10
Li cation
Elevation Datum
PEERCOATION TESTS _-
DATES �°� Gw 2.7 G t,�a
Pit Number r3°° l �,,� i��^ 2 ���� �� t 1`L
Start Saturation 9: �2, �'« C opt :42'. ".
Soak-Minutes 1
F-1� " t�:a c'a Icy:«�Drop of 3"Time t i ( 11°2. o- li
DK2p 2f 6"-Time _ 1 tc�g Z`1 _.L?
M61",s.lst 3" drop t t °Z, is _.;
-Mins.2nd
r
J
BOARD OF HEALTH
DESIGN APPROVAL
r,
Lot # STREET "' Septic Tank.
Permit #
Proposed Construction
Approx Building Size
Garage Under Attached None 1
Min: elevation of top of slab �
7
Min elevation of top of foundation
Height of foundation wall ' (2
Footing in fill yes no
Further Comments
.,FCW Cy)F i) ) '
COMMONWEALTH OF MASSACHUSETTS �
EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS �i �
c� DEPARTMENT OF ENVIRONMENTAL PROTECTION .
ONE WINTER STREET. BOSTON. MA 03108 617.393-5$00
WILLIAM F,WELD TRUDY COXE
Govemo: Secretan
ARGEO PAUL CELLUCCI DAVID B.STRUMS
Lt.Governor SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM Commissioner
PART A
CERTIFICATION j& i/- i"t c]cy �N
. � c)
Property Address t„ Address of Owner:
Date ��Y. ,.. (If different)
P
Name of Inspector:
::a) t )ate W1 '... �w., , L..3
I"am a DEP
appro�yed system inspector pursuant to Section 15.340 of Title 5 (310 CMR 15.000)
Company Name: ,)e �)L ) .x w r e"
Mailing Address: ; ,"I ,
Telephone Number:
CERTIFICATION STATEMENT
I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate
and complete as of the time of inspection. The inspection was performed based on my training and experience in the proper function and
maintenance of on-site sewage disposal systems. The system: ,
000,041
�..
Passes
Conditionally Passes
® Needs Further Evaluation �y the (ocal ,Approving Authority
ils ,
Inspector's Signature; n
Date:
h
The System Inspector,;, hall submit a copy of this inspection report to the Approving Authority within thirty (30) days of completing this
inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit
the report to the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
INSPECTION SUMMARY: Check A, B, C, or D:
A] SYSTEMoPASSES:
"" I have not found any information which indicates that the system violates any of the failure criteria as defined in 310 CMR 15.303.
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 t6,be repla d or repaired. The system, upon
completion of the replacement or repair, as approved by the Board of Health, will ps's °'�,
Indicate yes, no, or not determined (Y, N, or ND). Describe basis of determination in all in 1itances. If"not'determined", explain why not.
The septic tank is metal, unless the owner or operator has provided the sys)tern jnspe (tor with a copy of a Certificate of
Compliance (attached) indicating that the tank was installed within twenty (20) years,prior to the date of the inspection; or
the septic tank, whether or not metal, is cracked, structurally unsound, shows susta
bntial infiltration or exfiltration, or tank
failure'is imminent. The system will pass inspection if the existing septic tank is replaced with a conforming septic tank
as approved by the Board of Health.
(revised 04/25/97) Page 1 of 10
DEP on the World Wide Web httpa/www magnet.state.ma,usldep
Printed on Recycled Paper
j
I
` I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
d PART A
... .. CERTIFICATION (continued) .
Jw
Prope y A dress:
so, � I
Owner:
Date of Inspection: '
I
E' B] SYSTEM CONDITIONALLY PASSES (continued)
® Sewage backup or breakout or high static water level observed in the distribution box is due to broken or obstructed
pipe(s) or due to a broken, settled or uneven distribution box. The system will pass inspection if(with approval of the
Board of Health). Describe observations:
broken pipe(s) are replaced
k
obstruction is removed , '
r
�)
distri bution-box is levelled or replaced
'
m- ,
pipe(s). The system M.
r
'The'systerri required,purr7ping more than four times a year due to broken or obstructed pi will pass i
inspection if(with approval of the Board of Health):
broken pipe(s) are replaced
obstruction is removed
i
Cj FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH:
Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect the
public health, safety and the environment.
1) SYSTEM WILL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER
, WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT:
® 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.
SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH (AND PUBLIC WATER SUPPLIER, IF APPROPRIATE) DETERMINES THAT
THE SYSTEM IS FUNCTIONING IN A MANNER THAT PROTECTS THE PUBLIC HEALTH AND SAFETY AND THE
ENVIRONMENT:
® The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet to a surface water supply or
tributary to a surface water supply.
® The system has a septic tank and soil absorption system and the SAS is within a Zone I of a public water supply well.
® )The system has a septic tank and soil absorption system and the SAS is within 50 feet of a private water supply well.
® The system has a septic tank and soil absorption system and the SAS is less than 100 feet but 50 feet or more from a
private water for coliform bacteria and volatile organic compounds hat
the'W ll is ppmPom pollution from dthat mfaee'distance and the presence of(am ammonia nitrogen vdininitrate nrnitogensisneq equal to or
less aPP
3) OTHER
(revived 04/25/97) Page 2 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART A
CERTIFICATION (continued)
Properly-�ddress: Al
Owner: .f f
Date of Inspection:
3 a
D] SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis
for this determination is identified below. The Board of Health should be contacted to determine what will be necessary to correct
''the failure,
Yes
No
Backu p of sewage into facility or system component due to an overloaded or clogged SAS or cesspool.
Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or
cesspool.
® Static liquid level in the distribution box above ouifet invert due to an overloaded or clogged SAS or cesspool.
_ liquid depth in cesspool is less than 6" below invert or available volume is less than 1/2 day flow.
® o Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s).
Number of times pumped ®.
Any portion of the Soil Absorption System, cesspool or privy is below the high groundwater elevation.
f Any portion of a cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply.
® V d Any portion of a cesspool or privy is within a Zone I of a public well.
® 0 Any portion of a cesspool or privy is within 50 feet of a private water supply well.
"
A)6 Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no
acceptable water quality analysis. If the well has been analyzed to be acceptable, attach copy of well water analysis for
coliform bacteria, volatile organic compounds, ammonia nitrogen and nitrate nitrogen.
E] LARGE SYSTEM FAILS:
You must indicate either "Yes" or "No" as to each of the following:
The following criteria apply to large systems in addition to the criteria above:
The system serves a facility with a design flow of 10,000 gpd or greater (Large System) and the system is a significant threat to
publir, health and safety and the environment because one or more of the following conditions exist:
Yes No
® the system is within 440 feet of a surface drinking water supply
® the system is within 204 feet of a tributary to a surface drinking water supply
® the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area- IWPA) or a mapped Zone II of a
4, public water supply well)
The owner or operator of any such system shall bring the system and facility into full compliance with the groundwater treatment program
requirements of 314 CMR 5.40 and 6.00. Please consult the local regional office of the Department for further information.
i
i
(revised 04/25/97) Page 3 of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART B
CHECKLIST
Property Idress: ..op^t, D
Owner: (or Ck
Date of Iiisliection:
Check if the following have been done: You must indicate either "Yes" or "No" as to each of the following:
Yes No
Pumping information was provided by the owner, occupant, or Board of Health,
00,00e
None of the system components have been pumped for at least two weeks and the system has been receiving normal
flow rates during that period. Large volumes of water have not been introduced into the system recently or
as part of this inspection.
As built plans have been obtained and'examined. Note if they are not availabl&,,,'with N/A.'
The facility or dwelling was inspected for signs of
sewage back-up.
00,
The system does not receive non-sanitary or industrial waste flow.
'00
The site was inspected for signs of breakout,
VOOO" All system components, excluding the Soil Absorption System, have been located on the site.
The septic tank manholes were uncovered, opened, and the interior of the septic tank was inspected for condition of
baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge, depth of scum.
The size and location of the Soil Absorption System on the site has been determined based on:
The facility owner land occupants, if different from owner) were provided with information on the proper maintenance of
Sub-Surface Disposal System.
Existing information. Ex. Plan at B.O.H.
Determined in the field (if any of the failure criteria related to Part C is at issue, approximation of distance is
unacceptable) [15.302(3)(b))
A
(revised 04/25/97) Page 4 of 10
atih
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION
Proper Address: �r�F' , .�, ) A10 A 0
Owner:"i ,
Date of Gpeki on:
FLOW CONDITIONS
RESIDENTIAL:
Design flow: g.p.d./bedroom for S.A.S.
Number of bedrooms: 2
LaudGarbage c grir der
r nectedeto s stem ( es or no)'
mw r, P&F""o .A' �,,..
Number of current res ents �,,
Laundry y y t.
Seasonal use (yes or no):
Water meter readings, if available (last two (2) year usage (gpd):
Sump Pump (yes or no):ILL
Last da' 41occupancy: ,"^
COMMERCI.AUI N D USTRIAL:
v�
Type of establishment:
Design flow: gallons/day
Grease trap present: (yes or no)_
Industrial Waste Holding Tank present: (yes or no)®
Nan-sartitary waste discharged to the Title 5 system: (yes or no)®
Water meter readings, if available:
Last date of occupancy:
OTHER: (Describe)
Last date of occupancy:
GENERAL INFORMATION
PUMPING RECORDS and sou e of informat1 n 1
System pumped as part of inspection: (yes or no) ">
If yes, volume pumped: gallons
Reason for pumping
TYPE OPYSTEM
JZ Septioftank/d isfribut ion 6ox/soil absorption systerri
Single'cesspool
Overflow cesspool
Privy ",
Shared system (yes or no) (if yes, attach previous inspection records, if any)
I/A Technology etc. Copy of up to date contract?
Other
PROXIMATE AGE of all components, date installed (if known) and source of information:
a" ;a / r
b
Sewage odors detected when arriving at the site: (yes or no)'
(revised 04/25/97) Page 5 of 10
I
uJ z.
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Proper+ Address;
� AJ
Owner:
Date of Inspection:
BUILDING SEWER:
(Locate on site plan)
Depth below grade:
Material of construction: cast iron 40 PVC other (explain)
Distance romp r)jyate water supply well or suction lirf-
31
` Diameter
Cott eats: (condition of Joints, venting, evidence leakage, etc.)
k
SEPTIC TANK:
(locate on site plan)
�," Depth below grade:
Material of construction: oncrete metal _Fiberglass _Polyethylene _other(explain)
If tank is metal, list age ® Is age confirmed by Certificate of Compliance ®(Yes/No)
L
Dimensions ""° t' o
Sludge depth:_
Distance from top of fudge to bottom of outlet tee or baffle: ,') °
Scum thickness: 11 &
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to botto ..of outlet tee or baffle:
Mow dimensions were determined:
f�m
Comments:
(recommendation
evidence for
of pumping,
)o dition of inlet and outlet tees or baffles,s, depth of liquid level in relation t evee o outlet i ert, tr ctur
integrity,
GREASE TRAP:
(locate on site#an)
�� P
Depth below grade:
Material of construction: —concrete ®metal _Fiberglass _Polyethylene �other(explain)
Dimensions:
Scum thickness:
Distance from top of scum to top of outlet tee or baffle:
Distance from bottom of scum to bottom of outlet tee or baffle:
Date of last pumping:
1,0,
Comments:
(recommendation for pumping, condition of inlet and outlet tees or baffles, depth of liquid level in relation to outlet invert, structural
integrity, evidence of leakage, etc.)
(revised 04/25/97) Page 6 of 10
I
i
1
1
P
I
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Prop rty Address: . ,, r .. °t p
Owner:
Date of Inspection:
�m
TIGHT OR HOLDING TANK: (Tank must be pumped prior to, or at time, of inspection)
(locate on site plan)
Depth below grade:
Material of construction: —concrete —metal —Fiberglass _Polyethylene ®other(explain)
i'
Dimensions:
Capacity: gallons
Desig gallons/daN °
Alarm el. Alarm in working order_Yes; No
( ff�
Date of previous pumping:
Comments:
(condition of inlet tee, condition of alarm and float switches, etc.)
rk
DISTRIBUTION BOX:
(locate on site plan)
Depth of liquid level above outlet invert:L14,1ei,
Comments:
f leakage into or out of box, etc.)
i u is d 4m � rence afsol�ids carrya eiderice of le
(not rf level and distribution ""
w° I
PUMP CHAMBER
(locate on site plan) w
Pumps in working order: (Yes or No)
Alarms in working order (Yes or No)
Comments:
(note condition of pump chamber, condition of pumps and appurtenances, etc.)
(revised 09/25/97) Page 7 of 10
i
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
I
SYSTEM INFORMATION (continued)
w " "
PPf1pr•y Address: d ° 5
Owner. .o �� N., ) � �
Date of Inspection-
SOIL ABSORPTION SYSTEM (SAS): '00 "tl
(locate on site plan, if possible; excava ion not required, but may be approximated by non-intrusive methods)
If not determined to be present, explain:
of
Type:
leaching pits, number:_
leaching chambers, number:
leaching galleries, number:
aching trenches, number,length: -`
aching fields, number, dimensions L��° �I�f �
overflow cesspool, number:
Alternative system:
Name of Technology:
Comments:
n of v etation etc.)
(noteo�nditio f soil s� sofn�yd�raulic"failure, level of ponding, condit � ^� � W 416 LL" 'w a„r�� p�
CESSPOOLS: _
(locate on site plan)
Number and configuration:
Depth-top of liquid to inlet invert:
Depth of solids layer:
Depth of scum layer:
Dimensions of cesspool:
Materials of construction:
Indication of groundwater:
inflow (cesspool must be pumped as part of inspection)
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
PRIVY:
(locate on site plan)
Materr als of construction: Dimensions:
Depth of solids:
Comments:
(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.)
(revised 04/25/47) Page a of 10
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Properk Address: A,I
Owner: K, 11"
(2�
Date of Inspe i ion:
SKETCH OF SEWAGE DISPOSAL SYSTEM:
include ties to at least two permanent references landmarks or benchmarks
locate all wells within 100' (Locate where public water supply comes into house)
Co,
.........
(revised 04/25/97) Page 9 of 10
l
SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM
PART C
SYSTEM INFORMATION (continued)
Prop y Address: , e
Owner: d
Date of nspecia '� r
Depth to Groundwater Feet
Please indicate all the methods used to determine High Groundwater Elevation:
t0'011 0bt ,fined from Design Plans on record
, Obs vation of Site (Abutting property, observation hole, basement sump etc.
Determine it from local conditions
) ��'
y eck with local Board of health
Check FEMA Maps
�w Chec pumping records
° Check local excavators, installers
Use USGS Data
Describe in your own words how you established the High Groundwater Elevation. Must be completed)
A
h �t
W y
4 c
4�
is 4.
IN
i
(revised 04/25/97) Page 10 of 10
I
Commonwealth of Massachusetts
City/Town of
M° System Pumping Record
Form 4
DEP has provided this form for use-by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility_ Information
1. System Location: Left/Right front of house, Left/Right rear of house,a rig side of hous , Left/
Right side of building, Left/Right front of building, Left/Right rear of building, Under
Address �t tk� M-L�l
Citylrown State \ Zip Code
2. System Owner: r
Name
Address(if different from location)
Cityrrown State Z' Code
Telephone Number
B. Pumping Record
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? ❑ Yes ❑ No
5. Conditi n f System:
6. System Pumped By:
Neil Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc
Company
7. Lo 'sr}vet contents were disposed:
ISignt PHaule)) Lowell Waste Water )
�y
Date
t5form4.doca 06103 System Pumping Record•Page 1 of 1
1
Commonwealth of Massachusetts
W City/Town of
System in Record � Ov ill"1
Form 4
DEP has provided this form for use by local Boards of Health. Other Lorms may be used, but t
information must be substantially the same as that provided here. B ittf� pq with your
local Board of Health to determine the form they use. The System P illy p.l e mNtf$itbe s bmitted to
the local Board of Health or other approving authority.
A. Facility Information
1. System Location: Left front of house, right front of house, ft side of h9�4 e, ight side of house, Left
rear of house, right rear of house, left side of building, right rear of building, under deck.
City/Town State Zip Code
2. System Owner: ( y
Name
Address(if different from location)
City/Town S#atl �� � �� �Zip Code
Telephone Number
B. Pumping Record
1. Date of Pumping 2. Quantity Pumped:
Date Gallons
3. Type of system: ❑ Cesspool(s) . Septic Tank ❑ Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes L 'N0�. If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
6, System Pumped By:
Neil J. Bateson F5821
Name Vehicle License Number
Bateson Enterprises Inc.
Company
7. Loc tion where contents were disposed:
L.S.D. -)-Lo4IIWasjeWpter
Signatur of ,au r Date
t5form4.doc•06/03 System Pumping Record•Page 1 of 1
Commonwealth of ass chus tts
City/Town of
" AEI E
System 1 r
Form 4 �, o'-m A iC:DOVEHZ
DEP has provided this form for use by local Boards of Health. Ot cwf � � � ' a ,i he
information must be substantially the same as that provided here. Before using this form,check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility Information
Important: _
When on filling out 1. Syste Location: [ � f
computer, use
only the tab ke
to m y
move your
cursor-do not Citylrown State Zip Code
use the return
key. 2. System Owner: ti
VQJ .V
Name
awn Address(if different from location)
Citylrown Stat Zip Code
Telephone Number
B. Pumping ecr
1. Date of Pumping Date 2. Quantity Pumped: Gallons
3. Type of system: ❑ Cesspool(s) 3-Septic Tank ❑ Tight Tank
❑ Other(describe):
.r
4. Effluent Tee Filter present? ❑ Yes El"No o If yes, was it cleaned? ❑ Yes ❑ No
5. Condition of System:
_6x—V�'�--t (;-0 '4
6. system um �By: -�
_
Name
"` Vehicle License Number
Company
7. Location ere c ntent re ased:
Sign at a ter Date
i
t5form4.doc•06/03 System Pumping Record<Page 1 of 1
I
i
TOWN OF NORTH ANDOVER
SYSTEM PUMPING RECORD
DATE: - S- 1 -D'
SYSTEM OWNER &ADDRESS SYSTEM LOCATION
(example: left front of house)
t io�
DATE OF PUMPING: QUANTITY PUMPED �� �� GALLONS
CESSPOOL: NO Q YES SEPTIC TANK: NO YES
NATURE OF SERVICE: ROUTINE EMERGENCY
OBSERVATIONS:
GOOD CONDITION FULL TO COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACIFIELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER OTHER (EXPLAIN)
SYSTEM PUMPED BY:
COMMENTS:
lLm.✓ s e (/�
CONTENTS TRANSFERRED TO: '
i
Commonwealth of Massachusetts
Massachusetts
teen Put n ire Record
System Owner System Location
Date of Pumping: Quantity Pumped: (. � gallons
Cesspool; No Yes L) Septic Tank: No U Yes
System Pumped by: getrederf, gor License#
Contents transrerrred to : lawr�nc�3anit�ry pistrict
Date: Inspector: