HomeMy WebLinkAboutMiscellaneous - 1 LACY STREET 4/30/2018p
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Commonwealth of Massachusetts
W City/Town of North Andover
o System Pumping Record
Form 4
4M
SV
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
�n
xenon
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority within 14 days from the pumping date in
accordance with 310 CMR 15.351.
A. Facility Information
7,
System Location:
1 Lacy St
Address
North Andover
City/Town
2. System Owner:
Name
Address (if different from location)
City/Town
B. Pumping Record
1. Date of Pumping 5/13/11
Date
3. Type of system: ❑ Cesspool(s)
❑ Other (describe):
Ma
State
JUN -7 CU11
HEALTH DEPAI
01845
State
Telephone Number
2. Quantity Pumped:
® Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes ❑ No
5. Condition of System:
x soilds
6. System Pumped By:
Mike Snow
Name
Stewart's Septic Service
Company
7. Location where contents were disposed:
Stev�t'�-treatment PJAt. 20 So. Mill
tSi Pdture of Hjuler v
Signature f ility
Zip Code
Zip Code
1000
Gallons
❑ Grease Trap
If yes, was it cleaned? ❑ Yes ❑ No
Vehicle License Number
Ma 01835
Dat
Date
t5form4.doc• 03/06 System Pumping Record • Page 1 of 1
WELL DATABASE
ADDRESS: �.
AGE CF W �? fr : WELL DRLT r LR:
W�� °��'� ,T: WELL LOCATION:
x•
---WELL PERbET DATE: DE27H OF WELL:
TYPE OF WELL. DRILLEDr
b. DLC c_
=OEWATERBFARINC ROCK_
WATT ANALYSIS; DAT-
-- '� MN�NESE;i, Y N
E=IRON: Y N OTHF..R CONT,. -f N
WHELI.. DAT -ABASE.
ADDRESS: G
AGE OF WELL. -� WELL. DRILLER-
-7/= PERNIIT Fur: 3 3 3WELL OC'
. OC r�
TI" �
WELL; PERMITDATE. - a �/�' DEPiH OF WELL. j (2 -) ,
TYPE OF WEIL: a- DRILLS b. DUG- c_ LN���iOWN
TYPE OF WATER BEARIIiG ROCK:
WATER ANALYSIS DATE: - 2-o Z HIGH Mj4NGANESE: Y N
HIGH IRON: Y ON OT=R CONTANLP1i ANTS: Y N
WELL DATABASE
ADDRESS:
�49
AGE OF W L.LL : 7v ALL DRL L E..R:
r PE_3tifiTT: WELL LOCATION:~
—�WFLL PHR-NCT DATF:-
TYPE OF WELL: a_ DRZZE7i
TYPE OF- WATER BEARING ROCK:
- WA=t - ANALYSIS DAT- -
DEPTH OF WELL:
b. DUG
ErCIB=IRON: Y N OTS{ C
(WELL DATABASE.
r°
--- __
c. U,i (1 2 40T -'N d
c -
ADDRESS:
f�
AGE OF W'"r.1...L: —� WELL DRILLZ
WELL PLPM71 r: .3 3 -3 WELL LOCATION:
WELL PEFl2/LTDATE. Lt " a �— DEPTH OF WELL: (2
TYPE OF WEII : a.. DRILLS b. DUG c_ L1Ni�Y0rnW
TYPE OF WATER BEARING ROCK: L CF'i6zz{
WATER ANALYSIS DATE: O I-EGH MANGAlNESE: Y
HIGH IRON: Y ON OTHER CONT.AbE ANTS: Y N
Commonwealth of Massachusetts
-.City/Town of NORTH ANDOVER, MASSACHUS
System Pumping Record
y` Form 4
N
Important:
When filling out
forms on the
computer, use
only the tab key
to move your
cursor - do not
use the return
key.
seem
DEP has provided this form for use by local Boards of Health. The System Pumping Record must
be submitted to the local Board of Health or other approving authority.
A. Facility Information
1. System Location:
Address
U ity/ town
2. System Owner:
LA
Name
Address (if different from location)
City/Town
wumping Record
Date of Pumping
Type of system: ❑
❑ Other (describe):
7W .
State Zip Code
State Zip Code
Telephone Number
Date 2. Quantity Pumped:
Gallons
Cesspool(s) ''Septic Tank ❑ Tight Tank
4. Effluent Tee Filter present? ❑ Yes No If yes, was it cleaned? [I Yes [I No
5. Condition of System:
6. System Pumped B
4Name
V/.
37
Company
7. Location where contents were disposed:
Signature of ler
http://www.mass.gov/dep/wa /approvals/t5forms.htm#inspect
vehicle License Number
Date
t5form4.doc• 06/03
System Pumping Record • Page 1 of 1
�¢ Additions- and Septic # HD-O'
Systems
Why do 1 need this approval? The Health
Department must approve all applications for
additions to houses served by a septic system
before the Building Department will issue any
permit. This is because there are several things
that the Health Department must check, namely:
+ Does the addition meet setback
requirements?
• Is the septic system working now?
• Where exactly is the septic system?
• Will there be more flow to the system?
• Does the system currently comply with.
relevant regulations?
• Is the system large enough to handle any
extra flow?
• Is there room enough on the lot for a new
system and a reserve?
All these questions address the problem of
whether the septic system is or can be made
large enough for the maximum number of
people the house could hold. An addition of any
kind when there is a septic system on the site is
considered "new construction".
What do I need?: You will need to submit floor
plans for the proposed addition along with a
complete floor plan of all floors of the house as it
currently exists. The two plans should be in the
same scale. You will also need a certified plot
plan showing the outline of the existing house,
the proposed addition, the location of the septic
system, and any wells or pools on the site. These
should all be to scale. It is also recommended
that you have your septic system inspected by a
certified Septic System Inspector. It is important
that your inspector checks on the size of your
septic system as well as how well it is working.
Who do I see? See the Health Department if
you cannot locate the septic system; there may
be a plan on file. See the Zoning Officer to find
out if your lot and the proposed addition meet
Zoning requirements. Check with the
Conservation Department to discover whether
wetlands will be a factor in your project. Then
submit your entire package to the Health
Department for a decision on your septic
system's fate. A Civil Engineer could help you
with this process.
How do I do this?: To start the process you mus
first go to the Building Department and apply foi
a permit for an addition. You will pay a fee and
receive some paperwork. You will probably have
to go through the Conservation Commission
process if there are any wetlands anywhere near
your project site. If your site is located in too hake
Cochiewick watershed, then you should check
with the Planning Department to see if you need
a special permit. If you have submitted your
application to the Board of Health, staff can be
reviewing it while you are going through other
departmental processes. A final approval and
permission for a building permit will depend on
the approval of all pertinent departments.
Other .References:
• 310 CMR 15.000 Title 5 (You can
download a copy of Title 5 at
vvww.state.ma.uVdepfbrp/vvwm t5oub
tm)
• Town of North Andover Requirements fc
the Subsurface Disposal of Sewage
• List of properties in the Watershed (in the
Community Development and Services
office at 27 Charles Street)
Town of North Andover Health Department —Community Development & Services Division
This brochure is intended for education/ purposes only. It does not cover al/jurisdictions or scenarios thatyour
permit application maybe subject to. Permit applicatiohs are site specific.
TOWN OF NORTH ANDOV '1'1
L) A t'F. SYSTEM PUMPING RE(20RU
SYSTEM OWNER & ADDRESS SYSTEM LOCA
Alb,
IOCE�'NJED
1 zzn
R v ANDOVER
2WR OF 4o I e*.TmE�O
HEALTH
m
DATF OF PUMPING
... -QUANTITY PUMPED:
CLSSfWL: NO YES
l� SOPUITaflit: N0_
NA FURL OF V
SERVICE: ROUTINE MERGENcy.
013SERVA rIONS:
GOOD CONDFI-ION /FULL 'ro COVER
HEAVY GREASE BAFFLES IN PLACE
ROOTS LEACMELD RUNBACK
EXCESSIVE SOLIDS FLOODED
SOLID CAkRYC)V-ER'.OTHER EXPLAIN
systorn pwnp4;d by so
�:UMMENT'S,
YES
I EN I'S FKANSYERRED I'() m 14-6o �
M/N ,ak . AN JER/
'
TOWN OF NORTH ANDOVER ®f �" OF ;MEAL"i
SYSTEM PUMPING R_ECORZDI NO/ -420
S OWNER & ADDRESS
/ Cmc
,r/ o�rrU
SYSTEM LOCATION _..
(example: lef( from of hou�t)
U .'E OF �UiviPilvG: �6/0 .(�UANTITY PUMPED
11 .,)SPOOL: NO YES SEPTIC TANK: NO YES
",A -1 -'URE OF SERVICE, ROUTINE /--�EMERCENCY
Ali>FfRV \TIONS
GOOD CONDITION ��! FULL TO COVER
HC:AVY CREASE BAFFLES IN PLAC1-'
ROOTS LEACHFIELD RUNBACK...
EXCESSIVE SOLIDS FLOODED
SOLIDS CARRYOVER O�HFR (EXPLAIN)
>1
)VLM PUMPED BY (��'
1
U, I M FLATS
TIZANSFEIZIZED TO;
March 25, 1994
Ms. Sandy Starr
Board of Health
120 Main Street
North Andover, MA 01845
Re: Lot 1 Lacey Street
Dear Sandy:
As a follow up to our telephone conversation yesterday I have enclosed a copy of
the results from the deep hole observation test pit which were conducted on the
above -referenced lot on April 30, 1992. We realize that the deep holes will expire
on April 30 ,1994, and that you have waived the requirement for us to conduct the
tests again since we will be conducting percolation tests this season.
We would like to conduct percolation tests on the site in June at your
convenience. Please contact us to set up an appointment.
If you should have any questions regarding this matter please do not hesitate to
contact me. I have also enclosed a copy of the Form A plan dated March 15,
1989, for your use.
Very truly yours,
THOMAS E. NEVE ASSOCIATES, INC.
Thomas E. Neve, PE, PLS
President
TEN/km
• ENGINEERS •
447 Old Boston Road
(508) 887-8586
• LAND SURVEYORS •
U.S. Route #1
#311 FOLLANS.WPS
• LAND USE PLANNERS •
Topsfield, MA 01983
FAX (508) 887-3480
COMPLAINT NUMBER DATE:
#61- JULY 8, 1992
COMPLAINTANT:CHARLES MCLAUGHLIN CLOSE DATE:
ADDRESS:1 LACY STREET PHONE: 689-9267 qAld
OWNER:SCOTT FOLLENSBEE PHONE #: �/, WU a
ADDRESS : LOT BEHIND 1 LACY STREET 683 ..i
INSPECTION DATE: ORDER L DATE:
COMPLAINT:PERK HOLES 81FEET DEEP NEED TO BE FILLED IN. HE'S AFFAID HIS
CHI4t MIGHT FALL INTO THESE HOLES.
ACTION:
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Applicant
Site Location
Town of North Andover, Massachusetts
BOARD OF HEALTH
APPLICATION FOR SITE TESTING/INSPECTION
" �--o V
Form No. 1
190
Engineer —7-0""
NAME ADDRESS TELEPHONE
Test/Inspection Date and Time
�6 V-0
Fee I
CHAIRMAN, BOARD OF HEALTH
Test No. ��b �j
S.S. Permit No.—D.W.C. No.—C.C. Date—Plbg. Permit No.
Town of North Andover, Massachusetts Form No.1
t%ORTH, BOARD OF HEALTH
cl
�0 APPLICATION FOR SITE TESTING/INSPECTION
R�—
Applicant Q-A, I -A
NAME ADDRESS TELEPHONE
Site Location
Engineer
NAME ADDRESS TELEPHONE
Test/I nspection Date and Time
Fee—i
CHAIRMAN, BOARD OF HEALTH
I n I
Test No. --3- -
S.S. Permit No.—D.W.C. No.______C.C. Date—Plbg. Permit No
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Commonwealth of Massachusetts
North Andover, Massachusetts
System Pumping Record
System Owner & address:
Kevin Carney
1 Lacey Street
North Andover, MA
Location of system: Rear
Date of Pumping: November 23, 2007
Type of system: Septic Tank
Gallons Pumped: 1000 Gallons
System pumped by:
Service Pumping & Drain Co., Inc.
5 Hallberg Park
North Reading, MA
R C ----
MAR 14 4'."
TOWN OF Nr
HEALTH G
License #: BHP 2006 0680, 0750, 0751, 0752, 0753, 0754
Contents transferred to: Greater Lawrence Sanitary District
Date. November 23, 2007 h. rt Pumping Technician: CC
This is PROPRIETARY and CONFIDENTIAL information that may be used only
by the Board of Health for regulatory purposes
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