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HomeMy WebLinkAboutMiscellaneous - 101 CHRISTIAN WAY 4/30/2018Commonwealth of Massachusetts City/Town of System Pumping Record NORTH ANDOVER Form 4 ut the DEP has provided this form for use by local Bo rus that oovided heOre. Before using his form,ther forms may be used, check heck with your information must be substantially the same as t P Record must ch submitted to local Board of Health to determine the form they use. The System Pumping 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 Important: When fining out 1. System Location.- forms ocation:forms on the " computer, use - -- only the tab key Address to move your Zip Code cursor - do not �- - ---- - State CityrTown use the return key. 2. System Owner: - Name - -. Address (if different from location) — State Zip Code Cityrrown Telephone Number -_ — B. Pumping Record 1. Date of Pumping Date - 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) Septic Tank E]Tight Tank E] Grease Trap ❑ Other (describe): - 4. Effluent Tee Filter present? [1 Yes [A-140 If yes, was it cleaned? ❑ Yes ❑ No 5. Condition of System: a/ -- 6. System Pumped By: ... _-- - Li vehicle cense Number nn�A Name 1 t� Company .a � A b - 7. Location where contents were is __ _..._.. __.. Date Signature of Hauler Date Signature of Receiving Facility System Pumping Record • Page 1 of 1 15form4.doa 03106 Commonwealth of Massachusetts Massachusetts System Pumping Record System Owner Type: Emergency Routine Cesspool: No Yes Date of Pumping: �0 System Pumped By: Wind River Environmental, LLC Contents Transferred to: System Location Form 4 -- System Pumping Record !A'JLI _ V F'EA _i. Septic Tank: No = YesEZI Quantity Pumped: Gallons Permit #: Contents Disposed at: Y�q' / v 111 a <oe � 6`n� Date: Pumper Signature: Condition of System/Other Comments f ON Dep Approved Form -12/07/95 Commonwealth of Massachusetss Massachusetts System Pumping Record Location Type: Emergency � Routine Cesspool: No Yes Date of Pumping: System Pumped By: kind Riw Enw wunanto% LLC Contents transferred to: Contents Disposed at: Date: of System/other Comments Pumper Signature: �5 A2 Dep Approved Form - 12/07/95 Form 4 -- System Pumping c D E C 0 t 2005 TOW'S C)F ��JFZ JH ANDOVER HLALTH U1 L RTMENT Septic tank: IVo =Yes Efy Quantity Pumped: 1,1,,b Gallons Permit #: 0 M� i ©m FORM 4 - SYSTEM PUMPING RECORD CURRIER SEPTIC & DRAIN SERVICE 107 FOREST STREET; MIDDLETON, MA 01949 (978) 774-2772 COMMONWEALTH OF MASSACHUSETTS MASSACHUSETTS SYSTEM PUMPING RECORD SYSTEM OWNER: /76,q /,, e >a cf/54f"7 wG y 4�g;-?-Z/a6 DATE OF PUMPING: <7- 3 9,9 CESSPOOL: NO a YES SYSTEM LOCATION: S r c'/P QUANTITY PUMPED: / GALLONS SEPTIC TANK: NO F7 YES El]— SYSTEM l] - SYSTEM PUMPED BY: CURRIER SEPTIC & DRAIN SERVICE CONTENTS TRANSFERRED TO: �r L S DATE: 9--3-9,9 INSPECTOR:y- NEW ENGLAND ENGINEERING SERVICES INC North Andover Board of Health 120 Main Street North Andover, MA 01845 RE Title V Inspection Dear Sirs: May 30, 1995 Enclosed is a Title V Inspection report for 101 Christian Way, North Andover. The report indicates passed the inspection with several recommendations for small repairs to the D -box. If you have any questions, do not hesitate to call. Yours truly, Bgen-;Zin C. Os cd, Jr. 33 WALKER RD. - SUITE 22 - NORTH ANDOVER, MA 01845 - (508) 686-1768 8 ..Sewage odors detected when.arriving at the site, yes or no z v SUBSURFACESEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B -SYSTEM'INFORMATION continued SEPTIC TANK.: (rocate.on site plan) depth below grade y { material;.of construction./„ conc rete metal FRS' other(explain) dimensions : f i 6 .'y /0 sludge _`depth... o distance'from.top of sludge to bottom 'of outlet `tee or baffle scum thickness .... distance,from'top 0f scum to top of :outlet tee or baffle _ distance -from bottom of scum,to bottom of outlet tee or baffle Comments'. (recommendation for puMp.� g, condition`. of inlet and:. outlet tees:..or baffles, depth'of:',l :quid: lever in: relation to outlet invert : s,firucturai znte r t . g y,: evidence" of:'. eakage; recommendations -.for repairs, .' etc: ) 's7"19NIK , GO D Y4S' ' •.�..._�r 0 Q:D , DISTRIBUTION BOX: (l;ocate`°n site plan) depth of liquid level above' outlet invert Comments fi note if _level' and distributign. is ,equal, evidence' of solids carryover, evidence of .°leakage into or. out, of -box recommendation : for.. repairs,., etc.). Nd �`vi� E•vCc DF Cy3i?/1y 00se1� �'sr�1S, r5 f32eKF,u REtvR-.vA 2�'PAiQ 'l�iyE• ovT�t�- �i1'£ i5 GDwE'2 •sNq��,� 13���vEi � .PUMP CHAMBER cT (locate :on siteplan) `. pumps in working: order, . Yes . or 'no Comments: (note condition of pump chamber, condition of pumps and appurtenances,. recommendations for maintenance or.repairs,etc.) 2 o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM;:INFORMATION continued., y SOIL ABSORPTION SYSTEMJSAS�. ` (looate:on site plan, ifpossible; excavation not required, but may be :approximated, by non -intrusive methods) If not determined to bepresent, explains Type ',,leaching'pits and number= leaching chambers and number - leaching; galleries ,and number , leaching trenches, number,. length. leaching: fields, nuinbex, dimensions I FiEt;ra 4 <l•yE5 ��/xs'a ` overflow cesspool,.number Comments; "(,note condition of soil; signs of::hydraulic failure, level of ponding, condition of•vegetation, recommendations for maintenance or repairs, etc,.) i1J0 h+Y oR,4 u L/ C FA/L (//c2,�` i1ClrEi7�?'/O N ��N 1 F-0 iP �yl CESSPOOLS {locate�on site plan) number and configuration depth=top of..,�`Iiquid to -inlet invert <depth of solids.'layer ;depth of ,:scum layer dimensions of cesspool materials,_ of: construction ini-cat: '.on af.=,",roundwatez,' info ow (:cess,pool, must be` pumped 'as. .dart of `� nspection)'- 'COMM ents" e condition of 'soil,. signs of, hydraulic failure.;._level' of ponding, condition."of _vegetation,•recommendations for maintenance or. repairs, etc.) PRIVY : (locate:: on site plan) mat'erials,of construction dimensions depth of solids Comments: _ (note condition of soil, signs of,hydraulic'failure, -level of ponding, condticn"o'f vegetation, recdmmendations for maintenance or repairs,etc.) 10 2 o SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B SYSTEM;:INFORMATION continued., y SOIL ABSORPTION SYSTEMJSAS�. ` (looate:on site plan, ifpossible; excavation not required, but may be :approximated, by non -intrusive methods) If not determined to bepresent, explains Type ',,leaching'pits and number= leaching chambers and number - leaching; galleries ,and number , leaching trenches, number,. length. leaching: fields, nuinbex, dimensions I FiEt;ra 4 <l•yE5 ��/xs'a ` overflow cesspool,.number Comments; "(,note condition of soil; signs of::hydraulic failure, level of ponding, condition of•vegetation, recommendations for maintenance or repairs, etc,.) i1J0 h+Y oR,4 u L/ C FA/L (//c2,�` i1ClrEi7�?'/O N ��N 1 F-0 iP �yl CESSPOOLS {locate�on site plan) number and configuration depth=top of..,�`Iiquid to -inlet invert <depth of solids.'layer ;depth of ,:scum layer dimensions of cesspool materials,_ of: construction ini-cat: '.on af.=,",roundwatez,' info ow (:cess,pool, must be` pumped 'as. .dart of `� nspection)'- 'COMM ents" e condition of 'soil,. signs of, hydraulic failure.;._level' of ponding, condition."of _vegetation,•recommendations for maintenance or. repairs, etc.) PRIVY : (locate:: on site plan) mat'erials,of construction dimensions depth of solids Comments: _ (note condition of soil, signs of,hydraulic'failure, -level of ponding, condticn"o'f vegetation, recdmmendations for maintenance or repairs,etc.) .'.-.r,..,w........_-......... ._...,. .._., ....r....:r-. -.«,_.'....-.-.r.....--....._rawMlNrr vw�:++...:,i. __...- +r+�i�riyer...-. rr ..:.. ' 13 SUBSURFACE SEWAGE DISPOSAL..SYSTEM INSPECTION FORM PART.D CERTIFICATION 4, Name of Inspector Co`mpariy' Name F' uZrini Ew GtgAJ0 ZAJ GtAJ, 'ts'"IV - S BR vices c•vC, Company*Address. - 33 wr4LK, r—:Q f1D. N ANo:ovER MR• 0�8y,r Certification Statement. 1. certify ",that -I have =personally ilnspected the sewage disposal system at thus :address.. and that the information reported is true, accurate and rof compete as the time of"inspection. The inspection was performed and any recommendations regax.ding,upgrade,.mazntenance�and-repair are consistent with my tra ningl and ,experience in the' proper; functioh'and manitenance o"f: on -"site) sewage dirsposa.l systems. Chec ne. I,'have not found any informatioh'which,indicates that the: system fails to; adequately. protect public healthor the environment as defined in 310.: CMR 15.303. -Any.fai:lure criteria not evaluated areas stated, in the -FAILURE CRITERIA section of -this; form. I `have determine -6,7, that the system: fails .to protect .public 'health and the env ironment'as:.defined.in 310 CMR 15.303. The basis. for this determination is provided in the FAILURE CRITERIA Section of this, form . Inspector's -Signature 8Q 77— . Date /. Qriginal to system owner Coples,to:. .Buyer �,(if applicable) APprovi.rig authority Town of North Andover, Massachusetts Form No. 1 NoRTI,BOARD OF HEALTH F ' s,- 6'14, �� 6 0� 19 41, grEoWPPp.cS* APPLICATION FOR SITE TESTING/INSPECTION Applicant NAME ' � ADDRESS TELEPHONE Site Location Engineer NAME ADDRESS TELEPHONE Test/Inspection Date and Time Fee CHAIRMAN, BOARD OF HEALTH Test No. S.S. Permit No..D.W.C. No._C.C. Date Plbg. Permit No. 4QT /y ct-11�'15T1,4A-1 w4r Iz-T 7 f � 4QT /y ct-11�'15T1,4A-1 w4r Iz-T 7 (-0413D of rFAII- Nof�TH 4N pnvEl-� I MA, ss 7-95 4 PPi{O\ e) v (f©A,)PiTIO"5 = DI SQPPP v& -D Rt 45 tos = WATCR SOPPL7 LOT --' L4 CLE 5 Tw v LA �u J5 cc �cic r� �.QP`` CAtiJ I 1 I , I. I 1"-I I I a=1 , 56PT'I c S-► sTF� VE zA &AJ APRzavlN6 AUT►yo►?rry DLO(-- StPir c SvSTEM I J STA U-. TIOA J ' 7Fx4v4T(oIj WsnP 6TrO&J PI'NAL� iV5PFcrloA) APPRovEP PArE F4►L- QuC---12-- 1.5-x% APPta)VIn)G AUTHOJ-?rT F AVDITIOMAL 1 ,�j5 z-rjOtis X11= A►'Y) DiSAPPj?ov.✓D R�OSo rv$ , Fly 4L APRI DV4L DATE APP►3o,1rJ6 6u i riogl ► y G F-11C4RD of lvol - fl AULDNEl'�, MA, �. LOT ( G/ C f(r'i5 ! l/ ,✓ w ,'Y APPL(C�Iv I . r e , (�A"CER Sc� �I'L7 �6c�Jnl CJ WEt.c_ AP�ouCD 114tC SS z�3 StPr'ic s1►STE,," PES16J 7-201-a) APRWPJG /urho,?iry PCAnJ DESt GN�I�5--�� DISAPPRnVEp OgTE Cotjvlfbo J5 R�4SvNS = D ScPT'c c SYSTEM 1 J STA ULATI OA J G`X4V4Tto/&J 1NSn-.6► ro&j FINAL W 5P6—�-Tlon) Q PFRO\JED 94 r ATC 49P TIOIJA(, 1,A1SF6c.j (oNS DISAPt'J;�ovrlp 13CAS0N5 ', FVAL APPFOVAL Dare- Q RA5S El F4'L- APMDI J►ivG AOT- tfo ?iTy 1 NS%i01, c-(� Commonwealth of Massachusetts City/Town of NORTH ANDOVER, MASSACHUSETTS - System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. The ystern Pu pin R cord ust be submitted to the local Board of Health or other approving authoi ty. JAN (� � ���� Important; When filling out forms on the computer, use only the tab key to move your cursor - do not use the return key. serum A. Facility InformationI TOWN OFI HEALTH 1. System Location: Inj ChT-;s�i Address- City/TowrT — State 2. System Owner: KCv i n Nan If - Name Address (if different from location) City/Town B. Pumping Record 1. Date of Pumping 3. Type of system: ❑ ❑ Other (describe): 64". Zip Code State Zip Code _ 97R_ baa -�792 b Telephone Number I a- I r 09 2. Quantity Pumped: Date /5700 Gallons Cesspool(s) []Septic Tank ❑ Tight Tank 4. Effluent Tee Filter present? ❑ Yes [�'No 5. Conditionstem: _ 'a?QQo Sy -- If yes, was it cleaned? ❑ Yes D/No .6. System Pumped By: Jay) GaIlQn� _ Na N^A Vehicle License Number Company 7. Location where conteWWWW6ter Treatment Plant Ipswich, MQ nig Signature of Hauler Date http://www.mass.gov/dep/water/approvals/t5forms.htm#inspect t5form4.doc• 06/03 System Pumping Record • Page 1 of 1